Faculty Bibliography

Objective: The study compared the efficacy of 2 behavioral interventions to ameliorate organization, time management, and planning (OTMP) difficulties in 3rd- to 5th-grade children with attention-deficit/hyperactivity disorder (ADHD). Method: In a dual-site randomized controlled trial, 158 children were assigned to organizational skills training (OST; N = 64); PATHKO, a performance-based intervention that precluded skills training (N = 61); or a wait-list control (WL, N = 33). Treatments were 20 individual clinic-based sessions over 10-12 weeks. OST involved skills building provided primarily to the child. PATHKO trained parents and teachers to reinforce children contingently for meeting end-point target goals. Primary outcomes were the Children's Organizational Skills Scales (COSS-Parent, COSS-Teacher). Other relevant functional outcomes were assessed. Percentage of participants no longer meeting inclusion criteria for OTMP impairments informed on clinical significance. Assessments occurred at post-treatment, 1-month post-treatment, and twice in the following school year. Results: OST was superior to WL on the COSS-P (Cohen's d = 2.77; p < .0001), COSS-T (d = 1.18; p < .0001), children's COSS self-ratings, academic performance and proficiency, homework, and family functioning. OST was significantly better than PATHKO only on the COSS-P (d = 0.63; p < .005). PATHKO was superior to WL on most outcomes but not on academic proficiency. Sixty percent of OST and PATHKO participants versus 3% of controls no longer met OTMP inclusion criteria. Significant maintenance effects were found for both treatments. Conclusions: Two distinct treatments targeting OTMP problems in children with ADHD generated robust, sustained functional improvements. The interventions show promise of clinical utility in children with ADHD and organizational deficits. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

Objective: It is unknown whether prolonged childhood exposure to stimulant medication for the treatment of attention deficit hyperactivity disorder (ADHD) increases the risk for developing abnormalities in blood pressure or heart rate. The authors examined the association between stimulant medication and blood pressure and heart rate over 10 years. Method: A total of 579 children, ages 7-9, were randomly assigned to 14 months of medication treatment, behavioral therapy, the combination of the two, or usual community treatment. The controlled trial was followed by naturalistic treatment with periodic assessments. Blood pressure and heart rate data were first analyzed with linear regression models based on an intent-to-treat approach, using raw data and the blood pressure categories of prehypertension and hypertension. Currently medicated patients were then compared with never or previously medicated patients. Associations between cumulative stimulant exposure and blood pressure or heart rate were assessed. Results: No treatment effect on either systolic or diastolic blood pressure could be detected. Children who were treated with stimulants had a higher heart rate (mean=84.2 bpm [SD=12.4] on medication alone and mean=84.6 bpm [SD=12.2] on medication plus behavioral therapy) than those who were treated with behavioral therapy alone (mean=79.1 bpm [SD=12.0]) or those who received usual community treatment (mean=78.9 bpm [SD=12.9]) at the end of the 14-month controlled trial, but not thereafter. Stimulant medication did not increase the risk for tachycardia, but greater cumulative stimulant exposure was associated with a higher heart rate at years 3 and 8. Conclusions: Stimulant treatment did not increase the risk for prehypertension or hypertension over the 10-year period of observation. However, stimulants had a persistent adrenergic effect on heart rate during treatment

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

OBJECTIVE:: We investigated body image dissatisfaction and bingeing/purging characteristics of bulimia nervosa (BN) in the ongoing prospective follow-up of the Multimodal Treatment Study of Children with attention-deficit/hyperactivity disorder (ADHD). METHOD:: Participants were 337 boys and 95 girls with ADHD and 211 boys and 53 girls forming a local normative comparison group (LNCG), reassessed in midadolescence (mean age, 16.4), 8 years after original recruitment. RESULTS:: Youth with childhood ADHD showed more BN symptoms in midadolescence than did LNCG youth, and girls demonstrated more BN symptoms than did boys, with effect sizes between small and medium. Childhood impulsivity, as opposed to hyperactivity or inattention, best predicted adolescent BN symptoms, particularly for girls. Among youth with ADHD, treatment received during the follow-up period was not associated with BN pathology. DISCUSSION:: Both boys and girls with ADHD may be at risk for BN symptoms in adolescence because of the impulsivity central to both disorders. Int J Eat Disord 2009. (c) 2009 by Wiley Periodicals, Inc

The current study investigates the accuracy of self-perceptions of competence among 43 children with attention-deficit/hyperactivity disorder (ages 6.9-11.9; 37 boys) attending an 8-week empirically supported behavioral summer treatment program. Having inflated self-perceptions about one's competence at the beginning of the summer predicted poorer response to the intervention administered in the program as assessed by changes in observed conduct problems, peer-nominated social preference, and friendship. However, inflated self-perceptions at the start of the summer predicted reductions in self-reported depressive symptoms during the treatment period. Despite participating in an intensive intervention, there was high stability of children's biased self-perceptions regarding their performance

Parent-report of child homework problems was examined as a treatment outcome variable in the MTA-Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (ADHD). Five hundred seventy-nine children ages 7.0 to 9.9 were randomly assigned to either medication management, behavioral treatment, combination treatment, or routine community care. Results showed that only participants who received behavioral treatment (behavioral and combined treatment) demonstrated sustained improvements in homework problems in comparison to routine community care. The magnitude of the sustained effect at the 10-month follow-up assessment was small to moderate for combined and behavioral treatment over routine community care (d = .37, .40, respectively). Parent ratings of initial ADHD symptom severity was the only variable found to moderate these effects

The revised new forest parenting programme (NFPP) is an 8-week psychological intervention designed to treat ADHD in preschool children by targeting, amongst other things, both underlying impairments in self-regulation and the quality of mother-child interactions. Forty-one children were randomized to either the revised NFPP or treatment as usual conditions. Outcomes were ADHD and ODD symptoms measured using questionnaires and direct observation, mothers' mental health and the quality of mother-child interactions. Effects of the revised NFPP on ADHD symptoms were large (effect size >1) and significant and effects persisted for 9 weeks post-intervention. Effects on ODD symptoms were less marked. There were no improvements in maternal mental health or parenting behavior during mother-child interaction although there was a drop in mothers' negative and an increase in their positive comments during a 5-min speech sample. The small-scale trial, although limited in power and generalizability, provides support for the efficacy of the revised NFPP. The findings need to be replicated in a larger more diverse sample

BACKGROUND: Short-term treatment with the meth-ylphenidate transdermal system (MTS) has been well tolerated in several clinical trials in children with attention-deficit/hyperactivity disorder (ADHD). However, the effects of long-term use have not been systematically evaluated. OBJECTIVES: The primary objective of this study was to assess the 12-month tolerability of MTS in children with ADHD. Effectiveness was a secondary objective. METHODS: This Phase III study was a multicenter, 12-month, open-label, flexible-dose extension of 4 previous trials. In those studies, children aged 6 to 12 years with a diagnosis of ADHD (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria) received MTS, osmotic-release oral system methylphenidate, or placebo. At entry into the present study, the children either continued to receive their optimal dose of MTS (10, 15, 20, or 30 mg per 9-hour patch wear time) or underwent dose titration over 4 weeks to an optimal MTS dose, which was continued for the remainder of the study. Tolerability was evaluated based on adverse events (AEs), physical examinations, vital signs, electrocardiograms, laboratory tests, the Children's Sleep Habits Questionnaire, and the occurrence of application-site reactions. RESULTS: Of 327 enrolled subjects, 326 received treatment and 157 completed the study. The majority of enrolled subjects were male (64.8%) and white (73.7%), with a mean (SD) age of 9.2 (1.9) years. Two hundred sixty-five (81.3%) of the 326 subjects who received MTS reported AEs. AEs led to study discontinuation in 29 subjects (8.9%). The majority (98.3%) of treatment-emergent AEs were of mild or moderate severity. The most common AEs were decreased appetite (24.8%), headache (16.6%), upper respiratory tract infection (12.3%), cough (11.7%), pyrexia (10.1%), and decreased weight (10.1%). Of the 1118 AEs, 40.8% were considered possibly or probably related to study treatment. Three serious AEs (facial contusion, ankle fracture, and syncope) occurred and were considered unrelated to study treatment. Based on data collected across all study visits, application-site reactions generally consisted of mild erythema associated with mild discomfort at the patch site. Application-site reactions accounted for 22 (6.7%) study discontinuations. CONCLUSIONS: Slightly less than half (48.0%) of subjects completed this 12-month, open-label extension study of MTS. Most AEs were mild to moderate in severity and, with the exception of application-site reactions, were typical of those previously observed with methylphenidate. ClinicalTrials.gov identifier: NCT00151957

OBJECTIVES: To determine any long-term effects, 6 and 8 years after childhood enrollment, of the randomly assigned 14-month treatments in the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA; N = 436); to test whether attention-deficit/hyperactivity disorder (ADHD) symptom trajectory through 3 years predicts outcome in subsequent years; and to examine functioning level of the MTA adolescents relative to their non-ADHD peers (local normative comparison group; N = 261). METHOD: Mixed-effects regression models with planned contrasts at 6 and 8 years tested a wide range of symptom and impairment variables assessed by parent, teacher, and youth report. RESULTS: In nearly every analysis, the originally randomized treatment groups did not differ significantly on repeated measures or newly analyzed variables (e.g., grades earned in school, arrests, psychiatric hospitalizations, other clinically relevant outcomes). Medication use decreased by 62% after the 14-month controlled trial, but adjusting for this did not change the results. ADHD symptom trajectory in the first 3 years predicted 55% of the outcomes. The MTA participants fared worse than the local normative comparison group on 91% of the variables tested. CONCLUSIONS: Type or intensity of 14 months of treatment for ADHD in childhood (at age 7.0-9.9 years) does not predict functioning 6 to 8 years later. Rather, early ADHD symptom trajectory regardless of treatment type is prognostic. This finding implies that children with behavioral and sociodemographic advantage, with the best response to any treatment, will have the best long-term prognosis. As a group, however, despite initial symptom improvement during treatment that is largely maintained after treatment, children with combined-type ADHD exhibit significant impairment in adolescence. Innovative treatment approaches targeting specific areas of adolescent impairment are needed