ObjectivesTo evaluate the efficacy of regular monthly follow up in maintaining treatment gains versus follow up as needed in the community for children ages 6 to 12 years with ADHD.MethodsOne hundred and eighty six children, age 6 to 13 with DSM-IV diagnosed Attention Deficit Hyperactivity Disorder (ADHD) (combined presentation) received 3 months of comprehensive treatment which included long-acting stimulant medication titrated to optimal dose (via parent and teacher reports) and weekly parent training groups and child social skills and academic training. After the 3 months of treatment, children were randomized to either monthly follow up by the research team (treatment group) or follow up as usual in the community (control group). Comprehensive evaluations occurred at 3 months at the end of the comprehensive treatment, and at 6, 12, 18, and 24 month follow-up.ResultsChildren in both groups improved significantly in all domains after the 3 months of intensive comprehensive treatment. Treatment gains were maintained during the 2 year follow up period in both groups. However, the Hyperactive/Impulsive rating in Conners scale by parent report and some teacher reports were worse in the community group during the follow-up period.ConclusionThe importance of the initial intensive comprehensive 3 month treatment cannot be underestimated as these treatments resulted in significant improvements which were maintained for 2 years in both groups. Factors such as social economic status and available community treatment which may have influenced these results are discussed.

Objective: To characterize the size and course of placebo response in attention-deficit/hyperactivity disorder (ADHD), with informant and moderator effects, and illustrate its importance by comparison to Multimodal Treatment Study of ADHD (MTA) 3-month data. Methods: In two randomized clinical trials parents and teachers rated DSM-IV ADHD symptoms (Sx) on pill placebo at baseline (BL), 8, 12, and 16 weeks for 57 children age 5-12 with ADHD (25 inattentive, 32 combined type) and on an intense 12-week nonmedical control condition (NMCC) for 27 children age 6-12. Results: Parent- and teacher-rated placebo effects peaked at 12 and 8 weeks, respectively. Changes from BL are significant (p = 0.001) by parent and teacher on inattentive Sx (d = .60, .56 for pill placebo; d = 1.48, .51 for NMCC) and on hyperactive/impulsive Sx by parent (d = 0.48 pill; d = 1.26 NMCC). Teacher-rated hyperactive/impulsive show greater placebo effect September-January than February-May (p = 0.017). Teacher-rated inattentive Sx shows a significant (p = 0.033) interaction of season*subtype. Compared to placebo data, MTA treatments show significant benefit (p = 0.000) at 3 months on both inattentive and HYP/IMP symptoms for medication management and combination groups but not for behavioral treatment (Beh) or community comparison groups, except for teacher-rated HYP/IMP for Beh (p = 0.002). Conclusions: Parent/teacher ratings show a medium placebo effect for pill placebo and a large effect (d > 1.2) by parent for intense, complex NMCC, suggesting that parent-rated placebo response depends on the complexity/intensity of the control condition. Raters agree on inattentive but diverge on HYP/IMP Sx. Teachers' perceptions of HYP/IMP severity change by season. Pill placebo data indirectly support the 3-month efficacy of two MTA treatments, combination and medication management.

BACKGROUND:Limited research exists on key issues that healthcare professionals perceive as important for optimizing Attention-Deficit/Hyperactivity Disorder (ADHD) care. This study identified the top ten priorities that healthcare professionals consider vital to support ADHD care in Canada. METHODS:A three-round online Delphi study was conducted using electronic surveys from 2022-2024 across Canada. In Round 1, healthcare professionals were asked to rate 21 predetermined items using a 5-point Likert scale and re-evaluated those rankings in Round 2. In Round 2, a new set of 34 items identified from Round 1 were rated and the rankings re-evaluated in Round 3. Consensus was determined by percentage agreement ≥ 90% with a Likert score ≥ 4. For each priority item, the mean Likert score, standard deviation, 95% confidence interval (CI), and the minimum and maximum Likert scores were calculated. RESULTS:96 Canadian healthcare professionals completed Round 1. 82 (85% response rate) completed Round 2 and 73 (89% response rate) completed Round 3. The two highest ranked priorities that achieved 100% consensus agreement were: providing access to well-trained healthcare providers in ADHD (mean score 4.74, 95% CI 4.65-4.84) and access to ADHD-related services (mean score 4.50, 95% CI 4.39-4.61). Among the top ten consensus-derived items, the highest frequency pertained to providing access to healthcare experts in ADHD and related-services (50%) followed by research into ADHD on socio-emotional functioning, co-existing conditions and in diagnosing ADHD in females (30%). Increasing knowledge and educating healthcare professionals and school systems on ADHD was also identified among the top ten priorities (20%). CONCLUSIONS:Healthcare professionals identified ten top priorities by consensus where most focused on providing access to trained healthcare providers and services to support ADHD care in Canada. Implementing strategies to improve access on a national level will improve the quality of life for individuals living with ADHD.

BACKGROUND:Many children with attention-deficit/hyperactivity disorder (ADHD) demonstrate impairment in social skills. However, ADHD rarely occurs in isolation, with approximately one-third of children with ADHD having one additional disorder, and another third having two or three comorbidities. Few studies have considered the global and specific patterns of social skill performance based on comorbidity status. METHOD:Using a large dataset containing 1400 carefully phenotyped children with ADHD (ages 7-12; 28% girls) in the United States and Canada, we characterized social skill deficit profiles associated with the presence of internalizing comorbidity (depression and/or anxiety), externalizing comorbidity (oppositional defiant or conduct disorder), and both internalizing + externalizing comorbidities. All children had parent and teacher ratings of social skills on a consistent measure, and we took a nuanced approach that considered both global social skills and specific subdomains of skills. RESULTS:Parent ratings indicated main and interaction effects of each comorbidity on lower social skill performance in a varied pattern. Both comorbidities were associated with poorer global social skills, responsibility, and self-control. In addition, internalizing was associated with poorer assertion, while externalizing was associated with poorer communication, cooperation, and empathy. Interaction effects suggested that the impact of externalizing overshadowed internalizing for poor responsibility and self-control; however, internalizing comorbidity attenuated the negative association between externalizing comorbidity and empathy. On teacher ratings, only externalizing comorbidity was associated with poorer global social skills, communication, cooperation, assertion, responsibility, empathy, and self-control. In addition, girls and younger children tended to have poorer global social skills (using a gender-normed standard score), while girls and older children showed better specific social skills (using a raw, not gender-normed score). CONCLUSION:Children with ADHD and these comorbidities had poorer social skills relative to children with ADHD only, as perceived by parents and teachers. There also may be different social skill profiles depending on the comorbid condition and informant. These findings may inform more personalized social skill interventions for children with ADHD.

Objectives: Recent studies report a fluctuating course of attention-deficit/ hyperactivity disorder (ADHD) across development characterized by intermittent periods of remission and recurrence. In the Multimodal Treatment of ADHD (MTA) study, we investigated fluctuating ADHD including clinical expression over time, childhood predictors, and between- and within-person associations with factors hypothesized as relevant to remission and recurrence. Methods: Children with DSM-5 ADHD, combined type (N = 483), participating in the MTA adult follow-up were assessed 9 times from baseline (mean age = 8.46) to 16-year follow-up (mean age = 25.12). The fluctuating subgroup (63.8% of sample) was compared to other MTA subgroups on variables of interest over time. Results: The fluctuating subgroup experienced multiple fluctuations over 16 years (mean = 3.58, SD = 1.36) with a 6- to 7-symptom within-person difference between peaks and troughs. Remission periods typically first occurred in adolescence and were associated with higher environmental demands (both between- and within-person), particularly at younger ages. Compared to other groups, the fluctuating subgroup demonstrated moderate clinical severity. In contrast, the stable persistent group (10.8%) was specifically associated with early and lasting risk for mood disorders, substance use problems in adolescence/ young adulthood, low medication utilization, and poorer response to childhood treatment. Protective factors were detected in the recovery group (9.1%; very low parental psychopathology) and the partial remission group (15.6%; higher rates of comorbid anxiety). Conclusions: In the absence of specific risk or protective factors, individuals with ADHD demonstrated meaningful within-individual fluctuations across development. Clinicians should communicate this expectation and monitor fluctuations to trigger as-needed return to care. During remission periods, individuals with ADHD successfully manage increased demands and responsibilities. Trial Registration: ClinicalTrials.gov identifier: NCT00000388.

Quarantine measures imposed due to COVID-19 have negatively impacted individual wellbeing. However, the research on the factors impacting mental health and functioning of families is limited. The current study explores socio-economic and demographic factors that mediate poor family functioning, anxiety, and depressive symptoms in response to quarantine measures in Canadian parents and children. 254 Canadian families completed an online questionnaire capturing demographic information and mental wellbeing of individuals and of the whole family. Family functioning was assessed using the Family Assessment Device General Functioning subscale (FAD-GF), and individual mental wellbeing was measured with the Generalized Anxiety Disorder screener (GAD-7) and Patient Health Questionnaire (PHQ-9). Generalized linear models and logistic regression were used to model socio-demographic impacts on outcome variables. Problematic family functioning was found in 78.5% of families with a high proportion of parents reporting above-threshold symptoms of anxiety (62.9%) and depression (73.4%). Many children also reported above-threshold symptoms of anxiety (54.6%) and depression (70.7%). Family functioning was impacted by parent and child age, parental employment status and pre-existing conditions for children. Anxiety and depression experienced by parents and children was increased in families with parents aged <45, household income<$100,000 pre-existing psychiatric conditions, or having a child aged >5 years. These findings show that most Canadian families observed in this study experienced above threshold symptoms of anxiety, depression and poor family functioning. Our study provides an initial step towards identifying characteristics of at-risk families and targeting interventions to mediate negative effects of quarantining.

OPINION article Front. Psychiatry, 18 October 2023Sec. Adolescent and Young Adult Psychiatry Volume 14 - 2023 | https://doi.org/10.3389/fpsyt.2023.1277095

This study aims to examine the moderating role of individual (sex, symptom severity, and comorbid disorders) and familial (parental stress and parental depressive symptoms) factors on the improvement of organization, time management, and planning (OTMP) skills of youths with attention-deficit hyperactivity disorder (ADHD) following participation of families in a multimodal intervention targeting academic organizational skills. ADHD youths ( M = 12.04 years, SD = 0.44; first language: 85.7% French, 11.4% English) under optimized psychostimulant treatment and their parents were randomly assigned to either an intervention group ( n = 32; 21 boys and 11 girls) or a control group ( n = 38; 28 boys and 10 girls). A two-dimensional questionnaire was used to measure improvement of OTMP skills: Time Management and Planning and Memorization and Material Management (MMM) . Severity of inattention symptoms ( p < .01) moderates MMM skills’ improvement. The intervention was more efficacious in improving MMM skills of youths with more severe inattention symptoms under optimized psychostimulant treatment. No other moderating factors were observed. The intervention was effective in supporting ADHD youths improve their OTMP skills. The intervention appears to buffer the negative impact of inattention symptoms severity on MMM skills improvement.

Background: Attention deficit hyperactivity disorder is a common neurodevelopmental disorder. Accessing services for this disorder is a worldwide challenge and requires innovative interventions. Aims: We aimed to investigate the effectiveness of tele-collaborative care for attention deficit hyperactivity disorder in primary health care centres in Dubai. Methods: Six trained physicians started collaborative care clinics across Dubai. Eligible children aged 6-12 years attending primary health care centres with attention deficit hyperactivity disorder were randomly selected to receive tele-health collaborative care, or standard treatment. Baseline assessments were conducted using the Vanderbilt Behavioral Assessment Scale, the Columbia Impairment Scale, the Childhood Behavior Checklist, and the Strength and Difficulties Questionnaire. Waiting times and clinical and functional outcomes were measured in both groups and compared. Continuous variables were presented as means and standard deviations, categorical variables such as sex were presented as numbers and percentages, and continuous outcome variables were compared using the Student t-test. Results: Among the referred children (n = 112), 11 boys and 6 girls met the eligibility criteria (mean age 7.8 years). The dropout rate at 6 months in the control group was 80%, compared with 50% in the intervention group. The mean waiting time was significantly shorter in the intervention group (1.3 weeks) than the control group (7.1 weeks); P = 0.026. The mean difference in the Childhood Behavior Checklist total score over time was significantly higher in the intervention group (P = 0.042), but the mean difference in the Vanderbilt scale was not significant. Conclusion: Tele-collaborative care for children with attention deficit hyperactivity disorder within primary health care is feasible.

This study examines whether parenting practices contribute to the improvement of Organization, Time Management and Planning (OTMP) skills following an intervention aimed to support youths with Attention Deficit Hyperactivity Disorder (ADHD) and their parents during their transition to secondary school. Families were randomly assigned to an intervention ( n = 32) or a control group ( n = 35) and assessed at baseline (T1), post group (T2) and post-intervention (T3). The intervention combines three components (child group, parent group and mentorship). Multivariate regression analysis and test of indirect effects were conducted using PROCESS software. Intervention effects on OTMP skills improvement (T3) was significant both directly, and via parental consistency at T2. The study shows the relevance of targeting consistency in parenting practices at a pivotal moment for children, the transition between primary (Grade 6) to high school (Secondary 1). It also highlights the relevance of directly addressing OTMP skills with ADHD youths.

This Symposium will present new findings from the MTA regarding stimulant treatment and substance use (SU), driving infractions and crashes, and social skills. The MTA was a 7-site study involving 579 children with ADHD and 258 age- and sex-matched controls aged 7 to 9 years. They were randomized to 4 different treatment groups for 14 months and then followed prospectively roughly every 2 years to the mean age of 25 years. This Symposium will present adolescent and young adult follow-up data on stimulant treatment and SU as well as driving infractions and crashes and comorbidities in adulthood. Parent and teacher ratings of social skills and the impact of comorbidities will also be reported. Brooke Molina, PhD, will report on stimulant treatment and SU as reported by parents and young adults. No association was found between current or former stimulant treatment. Raza Qadri, MD, will report on driving infractions, crashes, and comorbidities. Subjects with persistent ADHD had more driving infractions and crashes than the controls. Those with comorbid anxiety or depression had more driving under the influence (DUI) events than those with only ADHD or controls. Caroline Miller will report on 1400 children (576 from the MTA) aged 7 to 12 years who had parent and teacher reports on the Social Skills Improvement System (SSIS) or its predecessor. Parents reported consequences of both internalizing and externalizing comorbidities, whereas teachers could only see consequences of the externalizing comorbidities. Stimulant treatment does not influence SU. Driving infractions and crashes were associated with persistence of ADHD, and comorbid anxiety or depression increased DUIs. Externalizing comorbidities were most evident in impairing social skills.

Postsecondary education and its predictors will be described in people with and without ADHD from 7 longitudinal, controlled, prospective follow-up studies: the Montreal Study, the New York Study, the Milwaukee Study, the Pittsburgh Study, the Massachusetts Study, the Berkeley Girls Study, and the MTA.

Objective To describe adult outcome of people with attention-deficit/hyperactivity disorder (ADHD) diagnosed in childhood and its several key predictors via a review of 7 North American controlled prospective follow-up studies: Montreal, New York, Milwaukee, Pittsburgh, Massachusetts General Hospital (MGH), Berkeley, and 7-site Multimodal Treatment Study of Children With ADHD (MTA). Method All studies were prospective and followed children with a diagnosis of ADHD and an age- and gender-matched control group at regular intervals from childhood (6-12 years of age) through adolescence into adulthood (20-40 years of age), evaluating symptom and syndrome persistence, functional outcomes, and predictors of these outcomes. Results The rates of ADHD syndrome persistence ranged from 5.7% to 77%, likely owing to varying diagnostic criteria and the source of information (self-report vs informant report) across the studies. However, all studies observed high rates of symptomatic persistence ranging from 60% to 86%. The 7 studies were largely consistent in finding that relative to control groups, research participants with childhood-diagnosed ADHD had significant impairments in the areas of educational functioning, occupational functioning, mental health, and physical health as well as higher rates of substance misuse, antisocial behavior, and unsafe driving. The most consistently observed predictors of functional outcomes included ADHD persistence and comorbidity, especially with disruptive behavior disorders. Conclusion Childhood ADHD has high rates of symptomatic persistence, which is associated with negative functional outcomes. Characteristics that predict these negative outcomes, such as comorbid disruptive behavior disorders, may be important targets for intervention.

This Clinical Perspectives will explore postsecondary education in people with and without ADHD and possible predictors and support needed for their success or failure at university.