Training Executive, Attention, and Motor Skills (TEAMS): a Preliminary Randomized Clinical Trial of Preschool Youth with ADHD
Halperin, Jeffrey M; Marks, David J; Chacko, Anil; Bedard, Anne-Claude; O'Neill, Sarah; Curchack-Lichtin, Jocelyn; Bourchtein, Elizaveta; Berwid, Olga G
This preliminary randomized controlled trial compared Training Executive, Attention and Motor Skills (TEAMS), a played-based intervention for preschool children with attention-deficit/hyperactivity disorder (ADHD), to an active comparison intervention consisting of parent education and support (ClinicalTrials.gov Identifier: NCT01462032). The primary aims were to gauge preliminary efficacy and assist in further development of TEAMS. Four- and 5-year-old children with ADHD were randomly assigned to receive TEAMS (Nâ€‰=â€‰26) or the comparison intervention (Nâ€‰=â€‰26) with blinded assessments by parents, teachers and clinicians ascertained pretreatment, post-treatment, and 1- and 3-months post-treatment. Changes in ADHD severity, impairment, parenting factors, and neuropsychological functioning over time as a function of treatment condition were assessed using the PROC MIXED procedure in SAS. Across most measures, significant main effects for Time emerged; both treatments were associated with reduced ADHD symptoms that persisted for three months post-treatment. There were no significant Treatment effects or Time x Treatment interactions on symptom and impairment measures, suggesting that the magnitude of improvement did not differ between the two interventions. However, significant correlations emerged between the magnitude of behavioral change, as assessed by parents and clinicians, and the amount of time families engaged in TEAMS-related activities during treatment. Across a wide array of parenting and neuropsychological measures, there were few significant group differences over time. TEAMS and other psychosocial interventions appear to provide similar levels of benefit. Play-based interventions like TEAMS represent a potentially viable alternative/addition to current ADHD treatments, particularly for young children, but more research and further development of techniques are necessary.
Practitioner Review: Assessment and treatment of preschool children with attention-deficit/hyperactivity disorder
Halperin, Jeffrey M; Marks, David J
BACKGROUND:Attention-deficit/hyperactivity disorder (ADHD) often emerges during the preschool years and remains impairing throughout the life span. Early identification and intervention may yield lasting benefits that alter the often-adverse trajectory of the disorder. METHODS:This Practitioner Review provides up-to-date information regarding the evaluation and treatment of ADHD in preschool children. The clinical presentation of ADHD in preschool children, its persistence into later childhood, the applicability of DSM-5 criteria for preschoolers with ADHD, and early predictors of long-term trajectories are addressed, as well as current findings from randomized controlled trials of both nonpharmacological and pharmacological interventions. RESULTS:Symptoms of hyperactivity/impulsivity extend down to age 3, but several inattention symptoms, as defined by DSM-V, less accurately differentiate preschoolers with and without ADHD. Most preschool youth with ADHD symptoms continue to manifest symptoms and impairment into school-age and adolescence. However, few predictors of persistence beyond early severity have been identified. Behavioral interventions constitute a first-line treatment for preschool ADHD symptoms, with telepsychiatry increasing in prominence to help to mitigate financial, geographic, and/or logistical barriers to care. Pharmacological interventions, particularly psychostimulants, also confer demonstrable benefits, yet efficacy and safety profiles are less desirable relative to findings in school-age youth. CONCLUSIONS:Acute treatments have demonstrable efficacy, but do not appear to fundamentally alter underlying mechanisms or long-term trajectories.
Sequenced neurocognitive and behavioral parent training for the treatment of ADHD in school-age children
Chacko, A; Bedard, A-C V; Marks, D; Gopalan, G; Feirsen, N; Uderman, J; Chimiklis, A; Heber, E; Cornwell, M; Anderson, L; Zwilling, A; Ramon, M
The present study examines the potential of sequencing a neurocognitive intervention with behavioral parent training (BPT) to improve executive functions (EFs), psychiatric symptoms, and multiple indices of functional impairment in school-age children aged 7 to 11 years who have been diagnosed with attention-deficit/hyperactivity disorder (ADHD). Specifically, in a randomized controlled trial design, 85 children were assigned to either Cogmed Working Memory Training (CWMT) followed by an empirically supported, manualized BPT intervention, or to a placebo version of CWMT followed by the same BPT intervention. Working memory maintenance (i.e., attention control/short-term memory), working memory processing and manipulation, ADHD and oppositional defiant disorder (ODD) symptoms, impairment in parent-child dynamics, familial impairment, and overall functional compromise were evaluated as outcomes. The results suggest specific effects of the combined CWMT and BPT program on verbal and nonverbal working memory storage and nonverbal working memory processing and manipulation but no incremental benefits in regard to ADHD symptoms, ODD symptoms, and functional outcomes. The present findings do not support the hypothesis regarding the complementary and augmentative benefits of sequenced neurocognitive and BPT interventions for the treatment of ADHD. These results, the study's limitations, and future directions for research are further discussed.
Low Working Memory rather than ADHD Symptoms Predicts Poor Academic Achievement in School-Aged Children
Simone, Ashley N; Marks, David J; Bedard, Anne-Claude; Halperin, Jeffrey M
This study examined whether working memory (WM), inattentive symptoms, and/or hyperactive/impulsive symptoms significantly contributed to academic, behavioral, and global functioning in 8-year-old children. One-hundred-sixty 8-year-old children (75.6% male), who were originally recruited as preschoolers, completed subtests from the Wechsler Intelligence Scale for Children-Fourth Edition, Integrated and Wechsler Individual Achievement Test-Second Edition to assess WM and academic achievement, respectively. Teachers rated children's academic and behavioral functioning using the Vanderbilt Rating Scale. Global functioning, as rated by clinicians, was assessed by the Children's Global Assessment Scale. Multiple linear regressions were completed to determine the extent to which WM (auditory-verbal and visual-spatial) and/or inattentive and hyperactive/impulsive symptom severity significantly contributed to academic, behavioral, and/or global functioning. Both auditory-verbal and visual-spatial WM but not ADHD symptom severity, significantly and independently contributed to measures of academic achievement (all p < 0.01). In contrast, both WM and inattention symptoms (p < 0.01), but not hyperactivity-impulsivity (p > 0.05) significantly contributed to teacher-ratings of academic functioning. Further, inattention and hyperactivity/impulsivity (p < 0.04), but not WM (p > 0.10) were significantly associated with teacher-ratings of behavioral functioning and clinician-ratings of global functioning. Taken together, it appears that WM in children may be uniquely related to academic skills, but not necessarily to overall behavioral functioning.
Early language mediates the relations between preschool inattention and school-age reading achievement
O'Neill, Sarah; Thornton, Veronica; Marks, David J; Rajendran, Khushmand; Halperin, Jeffrey M
OBJECTIVE: Early inattention is associated with later reading problems in children, but the mechanism by which this occurs is unclear. We investigated whether the negative relation between preschoolers' ADHD symptoms and 8-year-old reading achievement is directly related to the severity of inattention or is mediated by early language skills. METHOD: Children (n = 150; 76% boys) were evaluated at 3 time points: preschool (T1), mean (SD) age = 4.24 (.49) years; 1 year later (T2), mean (SD) age = 5.28 (.50) years; and during school age (T3), mean (SD) age = 8.61 (.31) years. At T1, parents' Kiddie-SADS responses were dimensionalized to reflect ADHD severity. Children completed the Language domain of the NEPSY (i.e., A Developmental Neuropsychological Assessment) at T1 and again at T2. At T3, children completed the Wechsler Individual Achievement Test, Second Edition Word Reading, Pseudoword Decoding, Reading Comprehension, and Spelling subtests, and their teachers completed ratings of Reading and Written Expression performance in school. The mediating effect of T2 Language on the relation between preschool Inattention and age 8 Reading was examined using the nonparametric bootstrapping procedure, while controlling for T1 Language. RESULTS: Language ability at T2 mediated the path from preschool inattention (but not hyperactivity/impulsivity) to 8-year-old reading achievement (both test scores and ratings) after controlling for preschoolers' language ability. CONCLUSIONS: Early attentional deficits may negatively impact school-age reading outcomes by compromising the development of language skills, which in turn imperils later reading achievement. Screening children with attentional problems for language impairment, as well as implementing early intervention for both attentional and language problems may be critical to promote reading achievement during school years. (PsycINFO Database Record
Impact of occupational, physical, and speech and language therapy in preschoolers with hyperactive/inattentive symptoms: A naturalistic 2-year follow-up study
Mlodnicka, Agnieszka E; O'Neill, Sarah; Marks, David J; Rajendran, Khushmand; Bedard, Anne-Claude V; Schneiderman, Robyn L; Basu, Bipasha; Halperin, Jeffrey M
OBJECTIVE: Impact of speech and language therapy (ST) and occupational/physical therapy (OT/PT) on language and motor skills was examined in hyperactive/inattentive children. METHODS: Preschoolers were divided into those receiving and not receiving ST or OT/PT. RESULTS: Children receiving ST showed no gains in language functioning relative to those not receiving ST. OT/PT yielded similar results for motor functions. Hours of a service did not predict improvement. However, children who received ST showed improvement in social skills. DISCUSSION: The apparent lack of benefit suggests the need for further investigation into efficacy of these treatments in hyperactive/inattentive preschool children.
Good Holders, Bad Shufflers: An Examination of Working Memory Processes and Modalities in Children with and without Attention-Deficit/Hyperactivity Disorder
Simone, Ashley N; Bedard, Anne-Claude V; Marks, David J; Halperin, Jeffrey M
The aim of this study was to examine working memory (WM) modalities (visual-spatial and auditory-verbal) and processes (maintenance and manipulation) in children with and without attention-deficit/hyperactivity disorder (ADHD). The sample consisted of 63 8-year-old children with ADHD and an age- and sex-matched non-ADHD comparison group (N=51). Auditory-verbal and visual-spatial WM were assessed using the Digit Span and Spatial Span subtests from the Wechsler Intelligence Scale for Children Integrated - Fourth Edition. WM maintenance and manipulation were assessed via forward and backward span indices, respectively. Data were analyzed using a 3-way Group (ADHD vs. non-ADHD)xModality (Auditory-Verbal vs. Visual-Spatial)xCondition (Forward vs. Backward) Analysis of Variance (ANOVA). Secondary analyses examined differences between Combined and Predominantly Inattentive ADHD presentations. Significant GroupxCondition (p=.02) and GroupxModality (p=.03) interactions indicated differentially poorer performance by those with ADHD on backward relative to forward and visual-spatial relative to auditory-verbal tasks, respectively. The 3-way interaction was not significant. Analyses targeting ADHD presentations yielded a significant GroupxCondition interaction (p=.009) such that children with ADHD-Predominantly Inattentive Presentation performed differentially poorer on backward relative to forward tasks compared to the children with ADHD-Combined Presentation. Findings indicate a specific pattern of WM weaknesses (i.e., WM manipulation and visual-spatial tasks) for children with ADHD. Furthermore, differential patterns of WM performance were found for children with ADHD-Predominantly Inattentive versus Combined Presentations. (JINS, 2016, 22, 1-11).
Latent profile analysis of neuropsychological measures to determine preschoolers' risk for ADHD
Rajendran, Khushmand; O'Neill, Sarah; Marks, David J; Halperin, Jeffrey M
BACKGROUND: Hyperactive/Inattentive preschool children show clear evidence of neuropsychological dysfunction. We examined whether patterns and severity of test scores could reliably identify subgroups of preschoolers with differential risk for ADHD during school-age. METHOD: Typically developing (TD: n = 76) and Hyperactive/Inattentive (HI: n = 138) 3-4 year olds were assessed annually for 6 years (T1-T6). Latent profile analysis (LPA) was used to form subgroups among the HI group based on objective/neuropsychological measures (NEPSY, Actigraph and Continuous Performance Test). Logistic regression assessed the predictive validity of empirically formed subgroups at risk for ADHD diagnosis relative to the TD group and to each other from T2 to T6. RESULTS: Latent profile analysis yielded two subgroups of HI preschoolers: (a) selectively weak Attention/Executive functions, and (b) pervasive neuropsychological dysfunction across all measures. Both subgroups were more likely to have ADHD at all follow-up time-points relative to the TD group (OR range: 11.29-86.32), but there were no significant differences between the LPA-formed subgroups of HI children at any time-point. CONCLUSIONS: Objective/neuropsychological measures distinguish HI preschoolers from their TD peers, but patterns and severity of neuropsychological dysfunction do not predict risk for ADHD during school-age. We hypothesize that trajectories in at-risk children are influenced by subsequent environmental and neurodevelopmental factors, raising the possibility that they are amenable to early intervention.
Reliable ratings or reading tea leaves: can parent, teacher, and clinician behavioral ratings of preschoolers predict ADHD at age six?
O'Neill, Sarah; Schneiderman, Robyn L; Rajendran, Khushmand; Marks, David J; Halperin, Jeffrey M
To assess the relative ability of parent, teacher, and clinician behavioral ratings of preschoolers to predict ADHD severity and diagnosis at 6 years of age. Hyperactive/inattentive preschoolers [N = 104, 75 % boys, Mean (SD) age = 4.37 (0.47) years] were followed over 2 years (mean = 26.44 months, SD = 5.66). At baseline (BL), parents and teachers completed the ADHD-RS-IV and clinicians completed the Behavioral Rating Inventory for Children following a psychological testing session. At age 6, [Mean (SD) age = 6.62 (0.35) years], parents were interviewed with the K-SADS-PL; teachers completed the ADHD-RS-IV; and laboratory measures of hyperactivity, impulsivity, and inattention were obtained from children. Hierarchical logistic and linear regression analyses examined which combination of BL ratings best predicted 6-year-old ADHD diagnosis and severity, respectively. At age 6, 56 (53.8 %) children met DSM-IV criteria for a diagnosis of ADHD. BL ratings from parent/teacher/clinician, parent/teacher and parent/clinician combinations significantly predicted children who had an ADHD diagnosis at age 6. Parent and clinician, but not teacher, behavior ratings were significant independent predictors of ADHD diagnosis and severity at 6-years-old. However, only clinician reports of preschoolers' behaviors predicted laboratory measures of over-activity and inattention at follow-up. Cross-situationality is important for a diagnosis of ADHD during the preschool years. Among parents, teachers and clinicians, positive endorsements from all three informants, parent/teacher or parent/clinician appear to have prognostic value. Clinicians' ratings of preschoolers' inattention, impulsivity and hyperactivity are valid sources of information for predicting ADHD diagnosis and severity over time.
A randomized clinical trial of Cogmed Working Memory Training in school-age children with ADHD: a replication in a diverse sample using a control condition
Chacko, A; Bedard, A C; Marks, D J; Feirsen, N; Uderman, J Z; Chimiklis, A; Rajwan, E; Cornwell, M; Anderson, L; Zwilling, A; Ramon, M
BACKGROUND: Cogmed Working Memory Training (CWMT) has received considerable attention as a promising intervention for the treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) in children. At the same time, methodological weaknesses in previous clinical trials call into question reported efficacy of CWMT. In particular, lack of equivalence in key aspects of CWMT (i.e., contingent reinforcement, time-on-task with computer training, parent-child interactions, supportive coaching) between CWMT and placebo versions of CWMT used in previous trials may account for the beneficial outcomes favoring CWMT. METHODS: Eighty-five 7- to 11-year old school-age children with ADHD (66 male; 78%) were randomized to either standard CWMT (CWMT Active) or a well-controlled CWMT placebo condition (CWMT Placebo) and evaluated before and 3 weeks after treatment. Dependent measures included parent and teacher ratings of ADHD symptoms; objective measures of attention, activity level, and impulsivity; and psychometric indices of working memory and academic achievement (Clinical trial title: Combined cognitive remediation and behavioral intervention for the treatment of Attention-Deficit/Hyperactivity Disorder; http://clinicaltrials.gov/ct2/show/NCT01137318). RESULTS: CWMT Active participants demonstrated significantly greater improvements in verbal and nonverbal working memory storage, but evidenced no discernible gains in working memory storage plus processing/manipulation. In addition, no treatment group differences were observed for any other outcome measures. CONCLUSIONS: When a more rigorous comparison condition is utilized, CWMT demonstrates effects on certain aspects of working memory in children with ADHD; however, CWMT does not appear to foster treatment generalization to other domains of functioning. As such, CWMT should not be considered a viable treatment for children with ADHD.