Objectives Evidence-based methods to deter the misuse of stimulant medications for attention-deficit/hyperactivity disorder (ADHD) are lacking. Diversion is the most common means by which stimulants are obtained for non-medical use and prevention should begin early. The current study is the first randomized controlled trial testing whether brief training of pediatricians in Stimulant Diversion Prevention (SDP) can reduce diversion by their adolescent patients with ADHD. Methods A cluster-randomized controlled trial was conducted across seven pediatric practices in the U.S. (ClinicalTrials.gov NCT03080259). A detailed description of the study protocol is provided as well as results for pre-registered primary and secondary outcomes. Results Thirty-two prescribing providers, 357 adolescent patients, and one parent or guardian for each patient participated. Three practices were randomly assigned to training, and four waves of electronic surveys were administered to all participants (at baseline and 6-, 12-, and 18-months post-training) with high retention (e.g., 89%–97% of providers, 92%–96% of patients). Methods for recruitment and retention and provider and staff training were successful: planned sample size at baseline was exceeded by 12% for providers and was 95% of planned patients; planned retention at 18-months was exceeded by 21% for providers and by 10% for patients; 99% of the patients’ providers received training. Patient diversion, however, was infrequent at baseline, with only one endorsement in the treatment-as-usual (TAU) group and none in the SDP group. Diversion remained infrequent across follow-ups (6.7% TAU; 3.7% SDP), rendering tests of group differences under-powered for trustworthy statistical comparisons. Group differences were not found for any pre-registered a priori primary or secondary outcomes; one exploratory group difference emerged: perceived negative social consequences of diversion was higher among patients whose providers were trained. Conclusions Pediatric practices can be successfully recruited, retained, and trained with a brief workshop on stimulant diversion prevention with, as previously reported, high rates of satisfaction and sustained implementation. Future research might benefit from focusing on older adolescent samples to assess proximal effects of physician training on stimulant diversion. Longitudinal follow-up into early adulthood of the adolescent patients in this study might reveal later-emerging benefits of the SDP training.
OBJECTIVES Cognitive behavioural therapy (CBT) is a first-line psychosocial treatment for adults with attention deficit hyperactivity disorder (ADHD). While its clinical efficacy has been the focus of considerable research, the acceptability of CBT for ADHD remains under-studied. This is a critical gap, as core ADHD deficits may impact on acceptability and, therefore, utility. This review evaluates CBT acceptability for adults with ADHD using the Theoretical Framework of Acceptability (TFA). METHOD Five databases (Scopus, PubMed, MEDLINE, Web of Science and PsycINFO) were systematically searched in February 2026. Twenty-one studies including randomised controlled trials, pilot, feasibility, qualitative and mixed-methods studies, were included. Data were integrated and mapped to the seven TFA domains. RESULTS Across studies, CBT acceptability in adults with ADHD most strongly explored the domains of affective attitude, intervention coherence, perceived effectiveness and self-efficacy. Acceptability was driven by skills training, psychoeducation, therapeutic support, accountability strategies, individualisation and diverse materials. Burden was linked to homework, cognitive load and treatment intensity, while opportunity costs and ethicality were rarely reported. Group and digital formats were generally acceptable but dependent on facilitation quality, accessibility and therapeutic presence. CBT for adult ADHD is most acceptable when it enhances affective response, understanding, perceived effectiveness and self-efficacy while minimising burden. CONCLUSIONS Acceptability is optimised through structured, flexible interventions with therapeutic support, accountability, individualisation and engaging delivery. Rather than being determined by intervention format alone, acceptability reflects the combined influence of intervention content, delivery approach and treatment intensity. Future research should use standardised, prospective measures of acceptability and further explore ethicality, burden and opportunity costs. (J. of Att. Dis. XXXX; XX(X) XX-XX).
Aims: Attention-deficit hyperactivity disorder (ADHD) is characterized by impairing and age-inappropriate inattention, hyperactivity, and impulsivity. Extended-release guanfacine hydrochloride (GXR) is a selective α2A-adrenergic agonist approved as mono- and adjunctive therapy to psychostimulant medications for ADHD. This multicenter retrospective study aimed to assess patients with ADHD initiating treatment with GXR as mono- and adjunctive therapy in a non-Western, real-world clinical setting. Methods: The study was designed as a naturalistic, Patient-Reported Outcome Measures (PROMs)-based, clinic-based, multi-center study; thirty-two child and adolescent psychiatry clinics from 26 cities located in seven geographical regions of Türkiye were included. Clinicians evaluated ADHD symptom severity at baseline and at the end of the 6th month with Clinical Global Impressions (CGI)-Severity, Improvement, and Adverse Effect scales while parents evaluated symptoms with the DSM-IV-Based Screening Scale for Disruptive Behavior Disorders. Adverse effects after GXR treatment were determined from patient records. Dose equivalents for stimulants, antidepressants, antipsychotics, and mood stabilizers used concurrently with GXR were calculated. Univariate and bivariate analyses along with linear mixed models were used to model change. Logistic regression was used to evaluate predictors of treatment response in sensitivity analysis. Results: Five hundred and sixty-seven patients ( n = 437, 77.1% male) with a mean age of 11.2 ( SD = 2.8) years were enrolled. Comorbid diagnoses were common (82.4%) along with combination therapy (85.0%). GXR at a median dose of 2.0 to 3.0 mg/day was associated with improvement and the rate of adverse effects was low. GXR showed differential symptom-domain effects, with greater improvement in hyperactive-impulsive (HI) compared to inattentive (IA) symptoms. Children with comorbid autism spectrum disorder (ASD; n = 175, 30.0% of the sample) showed notable clinical improvement. Response was modified by baseline symptom severity. Conclusion: GXR may be a viable treatment option for children and adolescents with ADHD and various comorbidities among Turkish youth in real-world clinical populations, with baseline symptom severity as a potential modifier of response. The differential response favoring HI symptoms and notable effectiveness in comorbid ASD represent clinically important findings of this naturalistic, PROM-based study.
Objective Symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD) are increasingly recognized among adults and frequently co-occur with substance use disorders (SUD). Changing guidelines and complexity of treatment merit a review of approaches for managing this diagnostic overlap among adults. Methods We conducted a systematic review for randomized controlled trials (RCT) and nonrandomized comparative studies (NRCS) focused on the benefits and harms of non-stimulant/nonpharmacological ADHD treatment compared to psychostimulant medications for those with comorbid ADHD and SUD by searching: Medline (via PubMed), Embase, and PsycINFO from inception to December 14, 2023, the Cochrane library from inception to January 30, 2024, and ClinicalTrials.gov from inception to February 23, 2024. After screening, evidence from eligible studies was qualitatively and quantitatively synthesized by a multidisciplinary team of researchers and clinicians. Results Of 6,419 unique records screened, six RCTs and one NRCS were eligible for review, analyzing a total of N = 662 people. There was no evidence of differences in ADHD treatment adherence, substance use, SUD symptom change, or substance abstinence in people with co-occurring ADHD and SUD who were not prescribed stimulant medications compared to people prescribed stimulants (low confidence for all). No significant difference was observed in the proportion of individuals with improved scores on the Clinical Global Improvement scale based on a pooled analysis of three studies (pooled OR = 1.27 [0.32, 5.09]). Although trending in a clinically positive direction, studies provide insufficient evidence (no conclusion) for ADHD symptom change, SUD treatment adherence, medication misuse/diversion, and measures of depression and anxiety. There was no evidence of a difference in various measures of adverse events (strength of evidence not assessed). Conclusions Significant limitations in the evidence base prevent the ability to draw substantial conclusions, and additional inquiry is recommended in future research. Available data, while limited, may indicate increased maintenance in SUD treatment for long-acting stimulants, and there is insufficient data to support the efficacy of non-stimulants for ADHD treatment in SUD patients. Though literature is minimal, a cautious interpretation suggests that current evidence does not support concerns that stimulant medications can precipitate substance-related problems in adults with co-occurring SUD and ADHD.
Background: Attention-deficit/hyperactivity disorder (ADHD) is characterized by core symptoms of inattention, hyperactivity, and impulsivity that are persistent and can interfere with daily functioning. Centanafadine is a norepinephrine, dopamine, and serotonin reuptake inhibitor (NDSRI) and cental nervous symstem simulant recently FDA approved for the treatment of ADHD in both adult and pediatric patients. This secondary analysis explores the efficacy of centanafadine for the treatment of ADHD core symptoms as measured by the clinical scales, Conners 3-Parent Short and Conners 3-Self-Report Short, in a children and adolescents over 6 weeks of treatment.Methods: Two phase 3, multicenter, randomized, double-blind, placebo-controlled trials were conducted in the United States and Canada (children: NCT05428033; adolescents: NCT05257265).This analysis included children (6-12 years) or adolescents (13-17 years) with a primary diagnosis of ADHD randomized (1:1:1) to receive once-daily extended-release high-dose centanafadine, low-dose centanafadine, or placebo for 6 weeks without initial titration. Secondary outcomes presented here include the change from baseline in Conners 3-Parent Short and Conners 3-Self-Report Short Inattention and Hyperactivity/Impulsivity T-scores over Weeks 1 to 6 analyzed using a mixed-effect model for repeated measures and a prespecified integrated analysis of clinically meaningful within-patient change for the Conners 3-Parent Short analyzed via a Cochran-Mantel-Haenszel test. Low-dose centanafadine did not meet the primary endpoint; therefore, low-dose data have been excluded from this presentation, and subsequent presented p-values are not controlled for multiplicity.Results: In children (mean age 9 years, 59% male) and adolescents (mean age 15 years, 59% male), centanafadine showed separation from placebo as early as Week 1 (the first postbaseline time point), with significant improvements in inattention at each study timepoint over Weeks 1 to 6 as reported by both caregivers (Conners 3-Parent Short) and adolescents (Conner 3-Self-Report Short). Hyperactivity/Impulsivity was also significantly improved with centanafadine in children and adolescents at each week from Weeks 1 to 6 based on the Conners 3-Parent Short T-scores and at Weeks 4, 5, and 6 for the Conners 3-Self-Report Short. Compared to placebo, children treated with centanafadine had a 55% higher chance, and adolescents had a 65% higher chance of experiencing clinically meaningful within-patient change in inattention and a 48% and 46% higher chance in hyperactivity/impulsivity, respectively.Discussion: Centanafadine was efficacious in children and adolescents with ADHD, providing robust caregiver-reported and self-reported improvements when compared with placebo in the core symptoms of inattention, hyperactivity, and impulsivity.Trial registration: ClinicalTrials.gov identifiers: NCT05257265 and NCT05428033.
