Behavioral Parent Training for Preschool ADHD: Family-Centered Profiles Predict Changes in Parenting and Child Outcomes
Objective: Behavioral parent training (BPT) is the first line of treatment for preschool-aged children with attention-deficit hyperactivity disorder (ADHD); however, clinically significant improvements are not universal. In the current study, we employ a person-centered approach to create subgroups of families based on the intersection of multiple parent, child, and family pre-treatment factors. Further, we explore the utility of pre-treatment family profiles in predicting post-treatment differences in observed parenting behavior (i.e., behavioral control, parental warmth) and clinically significant change in child ADHD and oppositional symptoms. Method: Longitudinal data were collected using observational and parent-, teacher- and clinician-reported assessments from 130 parent-child dyads (Mage= 3.57, rangeÂ = 3.0- 4.11, 73.8% male, 69.2% White, 25.6% Hispanic) participating in BPT. Results: Findings from the current study suggest three distinct family profiles, which consisted of one profile with high family stress (HFS) as evidenced by elevated symptomatology across parent, child, and family-level domains, a second profile with elevated parental anxiety (PA), and a final profile with elevated parental depression (PD). These family-centered profiles were differentially associated with changes in observed parenting practices. Specifically, the PD profile (39%) demonstrated minimal improvements in behavioral control and warmth following treatment. In contrast, the HFS profile (30%) only improved in behavioral control and the PA profile (31%) improved in both parenting domains following treatment. In addition, marginally significant differences in child oppositional and ADHD symptoms were observed across profiles. Conclusions: Family-centered approaches may be useful for selecting and implementing interventions.
Adapting an empirical clinic-based organizational skills training program for use in schools: Iterative development and pilot assessment
Effective organizational skills (e.g., time management, materials management, and task planning) are associated with academic success, yet some children struggle to gain these skills without intervention. While evidence-based organizational skills interventions for pediatric clinical populations exist, none target organizationally impaired general populations in a primary school setting. In Organizational Skills Training-School (OST-S), school professionals teach small groups of 4th"“5th grade organizationally impaired elementary school students skills associated with tracking assignments, managing materials, time management, and planning. This open pilot study of 33 students examined: a. the feasibility of adapting and implementing an established clinic-based, individualized treatment (OST-C) to a group format in a school setting, b. the program's acceptability among children, parents, and school partners, and c. whether participating children improved in the same functional areas that OST-C positively influenced. Results indicated that we could adapt the intervention, school partners could implement it, and participants could accept it. Pre-post improvements in organizational skills (as rated by parents, teachers, and children), homework problems, and academic performance demonstrated the potential effectiveness of OST-S, suggesting the need for further efficacy work.
Trajectories of Growth Associated With Long-Term Stimulant Medication in the Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder
OBJECTIVE:To estimate long-term stimulant treatment associations on standardized height, weight and BMI trajectories from childhood to adulthood in the Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder (MTA). METHOD/METHODS:Of 579 children with DSM-IV ADHD-Combined Type at baseline (ages 7.0-9.9 years) and 289 classmates (local normative comparison group, LNCG), 568 and 258 respectively, were assessed 8 times over 16 years (final mean age = 24.7). Parent interview data established subgroups with self-selected Consistent (N=53, 9%), Inconsistent (N=374, 66%), and Negligible (N=141, 25%) stimulant medication use, as well as cases starting stimulants prior to MTA entry (N=211, 39%). Height and weight growth trajectories were calculated for each subgroup. RESULTS:Height z-scores trajectories differed among subgroups (F=2.22, P<0.0001) and by stimulant use prior to study entry (F=2.22, P<0.001). The subgroup x assessment interaction was significant (F=2.81, P<0.0001). Paired comparisons revealed significant subgroup differences at end-point: Consistent shorter than Negligible (-0.66 z-units / -4.06 cm /1.6 inches, t=-3.17, P<0.0016), Consistent shorter than Inconsistent (-0.45 z-units / -2.74 cm / -1.08 inches, t=-2.39, P<0.0172), and the Consistent shorter than LNCG (-0.54 z-units/+3.34 cm/ 1.31 inches, t=-3.30, P<0.001). Weight z-scores initially diverged among subgroups, converged in adolescence, and then diverged again in adulthood when the Consistent outweighed the LNCG (+ 3.561 z-units / +7.47 kg / +16.46 pounds, P<0.0001). CONCLUSION/CONCLUSIONS:Compared with those negligibly medicated and the LNCG, 16 years of consistent stimulant treatment of children with ADHD in the MTA was associated with changes in height trajectory, a reduction of adult height, and an increase in weight and BMI.
Do parental ADHD symptoms reduce the efficacy of parent training for preschool ADHD? A secondary analysis of a randomized controlled trial
Previous studies have suggested that children with Attention-Deficit/Hyperactivity Disorder (ADHD) may benefit less from behavioral parent training (BPT) if their parents have high levels of ADHD symptoms. We conducted a secondary analysis of data from a randomized controlled trial to test the hypothesis that parental ADHD symptoms reduce the efficacy of two BPT programs in a sample of preschoolers with ADHD. One intervention was specifically designed for children with ADHD (NFPP: New Forest Parenting Programme) and one was designed for children with Oppositional Defiant Disorder (ODD) (HNC: Helping the Noncompliant Child). Neither intervention was adapted to address parental ADHD symptoms. This secondary analysis included data from 164 parents and their 3-4 year-old children who were randomly assigned to one of the two programs or a waitlist group. Children were compared on ADHD and ODD outcomes at post-intervention and a 6-month follow-up. The presence of parent ADHD symptoms reduced the efficacy of BPT in only one of 16 analyses. Implications and limitations (e.g., low baseline rate of parental ADHD symptoms) of the findings are provided.
Defining ADHD symptom persistence in adulthood: optimizing sensitivity and specificity
OBJECTIVE: Longitudinal studies of children diagnosed with ADHD report widely ranging ADHD persistence rates in adulthood (5-75%). This study documents how information source (parent vs. self-report), method (rating scale vs. interview), and symptom threshold (DSM vs. norm-based) influence reported ADHD persistence rates in adulthood. METHOD: Five hundred seventy-nine children were diagnosed with DSM-IV ADHD-Combined Type at baseline (ages 7.0-9.9 years) 289 classmates served as a local normative comparison group (LNCG), 476 and 241 of whom respectively were evaluated in adulthood (Mean Age = 24.7). Parent and self-reports of symptoms and impairment on rating scales and structured interviews were used to investigate ADHD persistence in adulthood. RESULTS: Persistence rates were higher when using parent rather than self-reports, structured interviews rather than rating scales (for self-report but not parent report), and a norm-based (NB) threshold of 4 symptoms rather than DSM criteria. Receiver-Operating Characteristics (ROC) analyses revealed that sensitivity and specificity were optimized by combining parent and self-reports on a rating scale and applying a NB threshold. CONCLUSION: The interview format optimizes young adult self-reporting when parent reports are not available. However, the combination of parent and self-reports from rating scales, using an 'or' rule and a NB threshold optimized the balance between sensitivity and specificity. With this definition, 60% of the ADHD group demonstrated symptom persistence and 41% met both symptom and impairment criteria in adulthood.
Young adult outcomes in the follow-up of the multimodal treatment study of attention-deficit/hyperactivity disorder: symptom persistence, source discrepancy, and height suppression
BACKGROUND: The Multimodal Treatment Study (MTA) began as a 14-month randomized clinical trial of behavioral and pharmacological treatments of 579 children (7-10 years of age) diagnosed with attention-deficit/hyperactivity disorder (ADHD)-combined type. It transitioned into an observational long-term follow-up of 515 cases consented for continuation and 289 classmates (258 without ADHD) added as a local normative comparison group (LNCG), with assessments 2-16 years after baseline. METHODS: Primary (symptom severity) and secondary (adult height) outcomes in adulthood were specified. Treatment was monitored to age 18, and naturalistic subgroups were formed based on three patterns of long-term use of stimulant medication (Consistent, Inconsistent, and Negligible). For the follow-up, hypothesis-generating analyses were performed on outcomes in early adulthood (at 25 years of age). Planned comparisons were used to estimate ADHD-LNCG differences reflecting persistence of symptoms and naturalistic subgroup differences reflecting benefit (symptom reduction) and cost (height suppression) associated with extended use of medication. RESULTS: For ratings of symptom severity, the ADHD-LNCG comparison was statistically significant for the parent/self-report average (0.51 +/- 0.04, p < .0001, d = 1.11), documenting symptom persistence, and for the parent/self-report difference (0.21 +/- 0.04, p < .0001, d = .60), documenting source discrepancy, but the comparisons of naturalistic subgroups reflecting medication effects were not significant. For adult height, the ADHD group was 1.29 +/- 0.55 cm shorter than the LNCG (p < .01, d = .21), and the comparisons of the naturalistic subgroups were significant: the treated group with the Consistent or Inconsistent pattern was 2.55 +/- 0.73 cm shorter than the subgroup with the Negligible pattern (p < .0005, d = .42), and within the treated group, the subgroup with the Consistent pattern was 2.36 +/- 1.13 cm shorter than the subgroup with the Inconsistent pattern (p < .04, d = .38). CONCLUSIONS: In the MTA follow-up into adulthood, the ADHD group showed symptom persistence compared to local norms from the LNCG. Within naturalistic subgroups of ADHD cases, extended use of medication was associated with suppression of adult height but not with reduction of symptom severity.
Which Type of Parent Training Works Best for Preschoolers with Comorbid ADHD and ODD? A Secondary Analysis of a Randomized Controlled Trial Comparing Generic and Specialized Programs
The present study examined whether the presence of comorbid ODD differentially moderated the outcome of two Behavioral Parent Training (BPT) programs in a sample of preschoolers with ADHD: One designed specifically for ADHD (NFPP: New Forest Parenting Programme) and one designed primarily for ODD (HNC: Helping the Noncompliant Child). In a secondary analysis, 130 parents and their 3-4 year-old children diagnosed with ADHD were assigned to one of the two programs. 44.6 % of the children also met criteria for ODD. Significant interactions between treatment conditions (NFPP vs. HNC) and child ODD diagnosis (presence vs. absence) indicated that based on some parent and teacher reports, HNC was more effective with disruptive behaviors than NFPP but only when children had a comorbid diagnosis. Further, based on teacher report, NFPP was more effective with these behaviors when children had a diagnosis of only ADHD whereas HNC was equally effective across ADHD only and comorbid ODD diagnoses. Comorbidity profile did not interact with treatment program when parent or teacher reported ADHD symptoms served as the outcome. Implications for clinical interventions are discussed and directions for future work are provided.
Functional Adult Outcomes 16 Years After Childhood Diagnosis of Attention-Deficit/Hyperactivity Disorder: MTA Results
OBJECTIVE: To compare educational, occupational, legal, emotional, substance use disorder, and sexual behavior outcomes in young adults with persistent and desistent attention-deficit/hyperactivity disorder (ADHD) symptoms and a local normative comparison group (LNCG) in the Multimodal Treatment Study of Children with ADHD (MTA). METHOD: Data were collected 12, 14, and 16 years postbaseline (mean age 24.7 years at 16 years postbaseline) from 476 participants with ADHD diagnosed at age 7 to 9 years, and 241 age- and sex-matched classmates. Probands were subgrouped on persistence versus desistence of DSM-5 symptom count. Orthogonal comparisons contrasted ADHD versus LNCG and symptom-persistent (50%) versus symptom-desistent (50%) subgroups. Functional outcomes were measured with standardized and demographic instruments. RESULTS: Three patterns of functional outcomes emerged. Post-secondary education, times fired/quit a job, current income, receiving public assistance, and risky sexual behavior showed the most common pattern: the LNCG group fared best, symptom-persistent ADHD group worst, and symptom-desistent ADHD group between, with the largest effect sizes between LNCG and symptom-persistent ADHD. In the second pattern, seen with emotional outcomes (emotional lability, neuroticism, anxiety disorder, mood disorder) and substance use outcomes, the LNCG and symptom-desistent ADHD group did not differ, but both fared better than the symptom-persistent ADHD group. In the third pattern, noted with jail time (rare), alcohol use disorder (common), and number of jobs held, group differences were not significant. The ADHD group had 10 deaths compared to one death in the LNCG. CONCLUSION: Adult functioning after childhood ADHD varies by domain and is generally worse when ADHD symptoms persist. It is important to identify factors and interventions that promote better functional outcomes.
An initial investigation of brain functional reorganization following organizational skills training in children with attention-deficit/ hyperactivity disorder [Meeting Abstract]
Objectives: Organizational Skills Training (OST), is a 10-week psychosocial intervention found effective in improving organizational, time management, and planning (OTMP) skills in children with Attention-Deficit/Hyperactivity Disorder (ADHD). Little is known about the feasibility of identifying brain markers for treatment response. Using resting state fMRI (R-fMRI), we aimed to examine neuronal correlates of post-treatment change as a first step toward larger controlled studies of objective predictors of treatment response. Methods: We examined pre- and post-OST R-fMRI data of 15 children (12 males; mean age: 9+/-1 year) with ADHD and significant impairments in OTMP skills indexed by total scores on Children's Organizational Skills Scales-Parent (COSS-P) or Teacher (COSS-T). Our primary outcome measure was the change in COSS-P scores. As secondary summary outcome measure, we used prepost Z-score differences averaged across COSS-T, Homework Problems Checklist, Academic Progress Report and Academic Performance Rating scales. We selected a priori the intrinsic functional connectivity (iFC) of the dorsal anterior cingulate cortex (dACC), based on its role on cognitive control. Multivariate distance matrix regression (MDMR) analysis additionally allowed for whole-brain explorations. Follow-up iFC analyses were conducted on regions with significant within-subject post-OST differences by MDMR analysis. Results: COSS-P decreased significantly (t=7.1, p< 0.0001). In a cluster involving striatum bilaterally, dACC iFC decreased post-OST; these decreases were positively correlated with COSS-P improvements (r=.34, NS) and to improvements in the summary outcome (r=.63; p<0.03). MDMR analyses revealed iFC changes in the right medial and lateral precentral cortex. Followup seed-based iFC analyses of this region showed significant decreases in cortico-striatal iFC post-OST. Conclusions: Results support the feasibility of identifying changes in brain iFC after OST. Two distinct analysis converged on decreased corticosubcortical iFC post-treatment which related to change in clinical measures. As decreases in striato-cortical iFC characterize typical development, results suggest regionally-specific enhanced maturational effects of OST
Is there an overlap in organizational skills impairment among children with autism spectrum disorder and attention deficit/ hyperactivity disorder? [Meeting Abstract]
Objectives: Organization, time management, and planning (OTMP) difficulties have an impact on a substantial proportion (~50 percent) of children with ADHD, and they improve with behavioral intervention. Given symptomatic overlap between ASD and ADHD, children with ASD may also experience OTMP impairments. To date, examinations of this domain in ASD are missing. Objectives include the following: 1) to characterize the nature and extent of OTMP deficits in children with ASD and identify rates of ADHD comorbidity in children with ASD with and without OTMP impairments (ASD+, ASD-, respectively); and 2) to identify similarities and differences between the ASD+ and ASD- subgroups and children with ADHD and OTMP impairments (ADHD+). Methods: We examined data (N = 85) of children aged 8-13 years with DSM-IV-TR diagnoses of ASD (n = 35) or ADHD (n = 31), as well as typically developing children (TDC) (n = 19). ANOVA compared the groups on parent scores on the Children's Organizational Skills Scale (COSS-P) and the subgroups on ASD traits, ADHD traits, and executive functions (ratings on the Social Responsiveness Scale, Conners' Parent Rating Scale, and Behavior Rating Inventory of Executive Functions). A threshold for significance was set at P = 0.01. Results: Children with ASD and ADHD had higher (i.e., more severe) COSS-P Total T scores than TDC. Forty-two percent of the children with ASD were ASD+ (i.e., COSS-P Total T >65), and 47 percent were categorized as ADHD+. Eighty-seven percent of the ASD+ had comorbid ADHD per clinician's interview, in contrast with only 27 percent of the ASD- subgroup. The severity of ADHD traits and executive dysfunction was no different between ASD+ and ADHD+ groups. In contrast, ASD- children had significantly lower ratings of ADHD and executive function severity than children with OTMP deficits. It is noteworthy that the ASD+ and ASD- groups differed in ASD ratings. Results were replicated with a second, independent sample group (N = 150). Conclusions: A substantial proportion of children with ASD exhibited OTMP functional impairment difficulties, which accompanied other symptoms typically observed in ADHD. Given the availability of evidence-based interventions for OTMP impairments in ADHD, adaptations of this intervention for this population may be warranted