Adolescents with ADHD are at increased risk for myriad functional impairments and comorbidities and need accessible, acceptable, and effective treatment options. Stepped care treatment models employ a “light touch” initial intervention dose to meet lower needs and to reserve mental healthcare system capacity for more severe concerns. The current study employed a mixed methods approach to evaluate the First Approach Skills Training–Parenting Teens (FAST-P) program, a modular 4-session caregiver intervention implemented via telemedicine “tele-group.” The program workbook and 2-hour training video are available free online at www.seattlechildrens.org/FAST. Twenty-two adolescents ages 13–17 with ADHD plus a caregiver enrolled in the study and completed the idiographic Top Problems interview and ratings at baseline and posttest. Caregivers attended the 4-session program and completed acceptability measures and a semistructured qualitative interview.Group fidelity, attendance, and participant satisfaction were high. After the group, there was significant improvement in caregivers’ top problems. Themes from interviews included nearly all caregivers perceiving benefit from the program, especially to their parenting perspective, understanding of their teen, and communication. Most would have appreciated more sessions and additional topics, but the majority did not plan to seek additional treatments. Program delivery cost to the clinic was $76 per participating family.FAST-P is a feasible, acceptable, and affordable program for a first step in a “stepped care” model for adolescents with ADHD, with the goal of reducing the need for higher-intensity services. While the program supported caregivers and they perceived benefits, many families indicated they may need more intensive services.

Attention-deficit/hyperactivity disorder (ADHD) is among the most prevalent disorders in adolescents. A recent survey found that 13.6% of 12- to 17-year-olds in the United States have a diagnosis of ADHD.1 Many children who are diagnosed with ADHD continue to meet ADHD diagnostic criteria as teenagers; other youth are diagnosed later due to a variety of factors, including prominent comorbid conditions, stigma, and limited awareness or detection in youth who show only inattention. More than half of adolescents with ADHD are treated with medication, with many receiving medication alone. Multimodal treatment is recommended because of the complementary benefits of pharmacotherapy on core ADHD symptoms and cognitive-behavioral interventions that target impairments.2 Compared with children, maintenance of pharmacotherapy is more difficult in adolescents due to nonadherence or early discontinuation.3-5 As a result, a new medication with an improved risk-to-benefit ratio, especially one that addresses more than core ADHD symptoms and adolescent-specific issues, represents a significant advance.

OBJECTIVE:To examine the Strengths and Weaknesses of ADHD-Symptoms and Normal Behavior scale (SWAN) clinical utility as a diagnostic measure of ADHD in an ADHD clinic sample. METHOD:In a sample of 357 children (6-11 years old) referred for evaluation at an academic medical center, we explored the SWAN's diagnostic and convergent validity with the Hyperactivity-Inattention subscale of the Strengths and Difficulties Questionnaire (SDQ/HI) and concurrent validity with the Impairment Rating Scale (IRS). RESULTS:The averaged (SWAN total) and the SWAN Hyperactivity/Impulsivity subscale (SWAN HI) showed significant and large correlations with the SDQ/HI (r = .69 and .65), respectively. The SWAN Attention Deficit subscale (SWAN AD) had a significant but smaller correlation (r = .49). The SWAN total had moderate correlation with the IRS average score ( = .33). In receiver operating characteristic (ROC) curve analyses (area under the curve (AUC) = 0.71) for the SWAN total, the SWAN distinguished ADHD cases from non-ADHD cases with sensitivity of 83% but specificity of 47%. CONCLUSION:In a clinical sample, the SWAN total scores displayed a near-normal distribution. ADHD cases were distinguished from non-ADHD cases by the SWAN. The SWAN showed adequate convergent and concurrent validity with other symptoms and impairment measures.

BACKGROUND:Attention deficit hyperactivity disorder (ADHD) is a 24-hour disorder that both impacts, and, is impacted by, daily activity and sleep. Children with ADHD are less likely to meet recommended 24-hour movement guidelines (ie, on average 60 min of moderate to vigorous physical activity and several hours of light activity per day, less than 2 h of screen time, and 9-11 h of sleep). The current study examined associations between meeting 24-hour movement guidelines with ADHD symptoms, sleep problems, and media use. METHODS:Accelerometer data measured physical activity and sleep among a sample of 93 children with ADHD (mean age = 8.10, SDage = 1.37, 58.9% male). Parent-report measures assessed ADHD symptoms, sleep difficulties, and media use. Multivariate analysis of covariance analyses explored associations between meeting 24-hour movement guidelines and outcomes. Latent class analysis (LCA) identified unique combinations of 24-hour movement guideline adherence. Associations were examined between classes and outcomes. RESULTS:Overall, 41.5% of children met physical activity guidelines, 23.4% met sedentary behavior guidelines, and 45.7% met sleep guidelines. Multivariate analysis of covariance analyses found that meeting more guidelines was associated with less sleep difficulties and problematic media use. LCA revealed 2 classes: Hypoactive children who were unlikely to meet activity guidelines and Work Hard, Play Hard children who were likely to meet activity and sleep guidelines. Children in the Work Hard, Play Hard class had less bedtime resistance compared with the Hypoactive class. CONCLUSION:Findings have implications for clinicians and caregivers supporting children with ADHD to take a holistic approach to improve health behaviors throughout the whole day.

Objective: To examine the effects of treatment sequence of parent stimulant medication (MED) and behavioral parent training (BPT) on child, maternal, and parenting outcomes among multiplex attention-deficit/hyperactivity disorder (ADHD) families using a pilot Sequential Multiple Assignment Randomized Trial (SMART) design. Methods: To be eligible, mothers had to meet DSM-IV diagnostic criteria for ADHD, and their children had to have elevated ADHD symptoms. Thirty-five mother-child dyads were randomized at baseline and again at week 8. The resulting 4 sequences were MED MED, BPT-BPT, MED-BPT, and BPT MED. Outcomes included child ADHD symptoms, child impairment, maternal ADHD symptoms, and parenting at week 16. Data were collected from September 2012 to December 2016. Results: The BPT-MED sequence demonstrated the most favorable outcomes for child ADHD symptoms (effect size= -0.36) and child impairment (effect sizes -0.33 to -0.51). All 3 sequences involving medication demonstrated similar impact on maternal ADHD symptoms (effect sizes ranged from -0.32 to -0.48). The BPT-MED (effect sizes ranged from 0.30 to 0.35) had the most favorable effects on positive parenting outcomes. For negative parenting outcomes, BPT-MED (effect size= -0.50 for self report) and BPT-BPT (effect size= -0.08 for observation) had the most favorable outcomes. Conclusions: Overall, based on this pilot SMART, combination treatment may be helpful for most multiplex ADHD families, and sequencing treatments with BPT first followed by stimulant medication for the mother may be the most promising approach to improve child ADHD symptoms, impairment, and parenting. These results require replication with a fully powered SMART design. We conclude with considerations for implementing a model of care for multiplex ADHD families. Trial Registration: ClinicalTrials.gov identifier: NCT01816074.

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder, with methylphenidate used as a first-line treatment. Methylphenidate is primarily hydrolyzed by carboxylesterase 1 (CES1) to inactive ritalinic acid, with minor oxidative metabolism producing active p-OH-methylphenidate and 6-oxo-methylphenidate lactam. The functional single-nucleotide polymorphism (SNP) in CES1, resulting in a glycine (G) to glutamic acid (E) substitution at 143 (G143E), is reported to significantly impair CES1 activity. However, limited clinical research has explored the pharmacokinetics of methylphenidate and its oxidation metabolites in ADHD therapeutics in G143E carriers. Three G143E ADHD subjects were genotyped for the G143E variant, and four non-carriers were identified and enrolled in the pharmacokinetic study. Participants received a single oral dose of methylphenidate, and plasma concentrations of methylphenidate, 6-oxo-methylphenidate, and p-OH-methylphenidate were extracted and quantified. Pharmacokinetic data were analyzed, and in vitro incubation of 6-oxo-methylphenidate with G143E S9 has been conducted. No significant differences were observed in the pharmacokinetics of methylphenidate. CES1 G143E carriers exhibited significantly elevated plasma concentrations of 6-oxo-methylphenidate, with a higher peak plasma concentration (Cmax), area under the curve from time zero to infinity (AUC0→∞), and longer half-life (T1/2). Reduced function in in vitro studies suggested the impaired CES-mediated biotransformation of 6-oxo-methyphnidate to 6-oxo-ritalinic acid. These results provide pilot data on the substrate-dependent impact of the CES1 G143E variant. Whether or not the elevated concentrations of 6-oxo-methyphenidate contribute to the clinical activity of methylphenidate treatment remains a matter of speculation. Registry: ClinicalTrials.gov, TRN: NCT03781752, Registration date: 4-March-2018.

Difficulties with sleep initiation and maintenance frequently occur in children with attention-deficit hyperactivity disorder (ADHD). All stimulants can produce insomnia, with little empirical data to suggest that there are substantial differences in sleep onset latency for the different stimulant formulations. While most children fall asleep with 15–20 minutes, children taking stimulant medications often take longer to fall asleep, especially during initial treatment and with dose increases. Insomnia related to stimulant medication appears to be dose-dependant, with 20%–30% of children treated in controlled trials taking more than 30 minutes to fall asleep when using low to moderate stimulant dosages. When initiating pharmacotherapy for ADHD, sleep patterns should be closely monitored. Sleep hygiene and behavioral procedures to reduce bedtime problems should be emphasized at all phases of ADHD treatment. If insomnia persists after initiating an effective ADHD treatment, alternative dosages, formulations, timing of administration or medications should be considered to produce optimal benefit during the day without compromising sleep. Presumably, reducing the variability in sleep–wake cycles due to ADHD pharmacotherapy will promote attention and alertness during the day.

Changing practice patterns caused by the pandemic have created an urgent need for guidance in prescribing stimulants using telepsychiatry for attention-deficit hyperactivity disorder (ADHD). A notable spike in the prescribing of stimulants accompanied the suspension of the Ryan Haight Act, allowing the prescribing of stimulants without a face-to-face meeting. Competing forces both for and against prescribing ADHD stimulants by telepsychiatry have emerged, requiring guidelines to balance these factors. On the one hand, factors weighing in favor of increasing the availability of treatment for ADHD via telepsychiatry include enhanced access to care, reduction in the large number of untreated cases, and prevention of the known adverse outcomes of untreated ADHD. On the other hand, factors in favor of limiting telepsychiatry for ADHD include mitigating the possibility of exploiting telepsychiatry for profit or for misuse, abuse, and diversion of stimulants. This Expert Consensus Group has developed numerous specific guidelines and advocates for some flexibility in allowing telepsychiatry evaluations and treatment without an in-person evaluation to continue. These guidelines also recognize the need to give greater scrutiny to certain subpopulations, such as young adults without a prior diagnosis or treatment of ADHD who request immediate-release stimulants, which should increase the suspicion of possible medication diversion, misuse, or abuse. In such cases, nonstimulants, controlled-release stimulants, or psychosocial interventions should be prioritized. We encourage the use of outside informants to support the history, the use of rating scales, and having access to a hybrid model of both in-person and remote treatment.

BACKGROUND:Attention Deficit/Hyperactivity Disorder (ADHD) demonstrates unique developmental manifestations in adolescence with implications for optimized, age-appropriate treatment. This 10-year update is the third in a series of systematic reviews examining the efficacy and safety of adolescent ADHD treatments. We broadly examined efficacy on ADHD symptoms, impairments, and other reported outcomes. Acute and long-term efficacy, and treatment moderators, were considered. METHOD:We performed PubMed, EMBASE, and PsycINFO searches for articles published or in press from 2013 to 2024, integrated with hand search and randomized controlled trials (RCTs) identified in this series' earlier reviews. RCTs examining the safety or efficacy of interventions delivered to adolescents (ages 10.0-19.9) with a diagnosis of ADHD were included. Study characteristics were extracted and reviewed, quality of evidence was assessed using GRADE, and effect sizes were calculated for individual studies and illustrated using forest plots. RESULTS:Sixty-three RCTs were identified. Quality of evidence ranged from high (medication; k = 29) to very low (nutrient supplementation, neurofeedback, occupational therapy; k = 1 each). Medications demonstrated consistent strong impact on ADHD symptoms and inconsistent impact on impairment. Diverse cognitive/behavioral treatments (C/BTs) demonstrated inconsistent impact on ADHD symptoms but strong and consistent impact on impairment and executive function skills, plus moderate benefits on internalizing symptoms. No interventions demonstrated significant safety concerns. Long-term maintenance (up to 3 years post-treatment) was demonstrated for C/BTs, though moderate quality of evidence was noted because participants cannot be fully blinded to receipt of treatment. CONCLUSIONS:The effects of C/BTs and medication appear complementary, not duplicative. Combining medication and C/BT is advised at treatment outset to maximize engagement, maintenance, and response breadth (i.e. improving both ADHD symptoms/cognitive performance and coping skills/functional impairments). Engagement strategies (e.g. motivational interviewing) may facilitate uptake. Novel treatments do not yet demonstrate effects on ADHD symptoms or impairments in adolescents but remain a promising area for research.

Background: Few biological or clinical predictors guide medication selection and/or dosing for attention-deficit/hyperactivity disorder (ADHD). Accumulating data suggest that genetic factors may contribute to clinically relevant pharmacodynamic (e.g., dopamine transporter-SLC6A3 also commonly known as DAT1) or pharmacokinetic (e.g., the drug metabolizing enzyme Cytochrome P450 2D6 CYP2D6) effects of methylphenidate (stimulant) and atomoxetine (non-stimulant), which are commonly prescribed medications. This is the first study of youth with ADHD exposed to both medications examining the clinical relevance of genetic variation on treatment response. Methods: Genetic variations in DAT1 and CYP2D6 were examined to determine how they modified time relationships with changes in ADHD symptoms over a 4-week period in 199 youth participating in a double-blind crossover study following a stepped titration dose optimization protocol. Results: Our results identified trends in the modification effect from CYP2D6 phenotype and the time-response relationship between ADHD total symptoms for both medications (atomoxetine [ATX]: p = 0.058, Methylphenidate [MPH]: p = 0.044). There was also a trend for the DAT1 3 ' untranslated region (UTR) variable number of tandem repeat (VNTR) genotype to modify dose relationships with ADHD-RS total scores for atomoxetine (p = 0.029). Participants with DAT1 9/10 repeat genotypes had a more rapid dose-response to ATX compared to 10/10, while those with 9/9 genotypes did not respond as doses were increased. Regardless of genotype, ADHD symptoms and doses were similar across CYP2D6 metabolizer groups after 4 weeks of treatment. Conclusions: Most children with ADHD who were CYP2D6 normal metabolizers or had DAT1 10/10 or 9/10 genotypes responded well to both medications. While we observed some statistically significant effects of CYP2D6 and DAT1 with treatment response over time, our data indicate that genotyping for clinical purposes may have limited utility to guide treatment decisions for ATX or MPH because both medications were generally effective in the studied cohort after 3 weeks of titration to higher doses. The potential DAT1 association with ATX treatment is a novel finding, consistent with prior reports suggesting an association of the DAT1 in 9/9 genotypes with lower responsive rates to treatment at low and moderate doses.

OBJECTIVE:Parent behavior management training (BMT) is an evidence-based yet underutilized tool to treat children with ADHD and address related health disparities. This pilot study investigated the acceptability and feasibility of a novel, health behavior-, and technology-adapted BMT (LEAP) vs. standard BMT. METHODS:The weekly 9-session LEAP telemedicine group program is based on a standard BMT curriculum enhanced with strategies for supporting optimal child sleep, problematic media use (PMU), and physical activity, including wrist-worn activity trackers. Children ages 6-10 years with ADHD and their caregivers were randomized to LEAP or standard BMT. Acceptability and feasibility were tracked. Caregivers completed standardized measures, and children wore hip-worn accelerometers for 1 week at baseline, postintervention (10 weeks), and follow-up (20 weeks). RESULTS:84 parent/child dyads were randomized to LEAP or standard BMT, with high and comparable acceptability and feasibility. Both treatment groups demonstrated decreased ADHD symptoms and improved executive functions postintervention (p < .0001), maintained at follow-up. Average accelerometer-measured MVPA decreased and sleep duration remained unchanged, while PMU and bedtime resistance improved for both groups. CONCLUSIONS:LEAP is highly feasible and acceptable, and yielded similar initial clinical and health behavior improvements to standard BMT. Innovative and targeted supports are needed to promote healthy behaviors in children with ADHD.

Background: Attention-deficit/hyperactivity disorder (ADHD) treatment utilization among adolescents is highly variable. This article describes pharmacological and nonpharmacological treatment utilization in a community sample of primarily Latinx and/or Black adolescents with ADHD (N = 218), followed longitudinally for 4 years, from early adolescence until approximately age 17 (M = 16.80, standard deviation = 1.65).Methods: Electronic surveys administered between 2012 and 2019 queried parent and youth reports of medication initiation, persistence, diversion, and misuse, as well as reasons for desistence. Nonpharmacological treatment utilization (including complementary and alternative treatments) was also measured.Results: Results indicated that: (1) the majority of the sample sought treatment for ADHD in their community, (2) rates of psychosocial treatment utilization were higher than medication utilization, (3) approximately half of the medicated sample discontinued community-administered ADHD medication during the follow-up period, most frequently citing tolerability issues and concerns that they were "tired of taking" medication, and (4) medication misuse consisted of youth diversion and parent utilization of teen medication, but both were reported at low rates. Race/ethnicity did not predict treatment utilization patterns, but lower family adversity and psychiatric comorbidity predicted persistence of medication use over time.Conclusions: ADHD treatment engagement efforts for Latinx and/or Black adolescents might link treatment to goals valued by the youth, address concerns related to medication tolerability, and promote secure monitoring of medication. Nonpharmacological treatments for ADHD may be more palatable to Latinx and Black youth with ADHD, and efforts to engage youth with ADHD in treatment should consider offering medication and psychosocial treatment options.

Pioneering longitudinal studies of boys with hyperactivity by Satterfield et al.1 indicated that one of the most deleterious outcomes associated with attention-deficit/hyperactivity disorder (ADHD) is later antisocial behaviors. This risk grows when ADHD is accompanied by severe behavior problems.2 Though most children with ADHD will not go on to engage in criminal behavior, dimensional measures of externalizing behavior problems as well as categorical diagnoses of oppositional defiant disorder and conduct disorder have strong associations with ADHD. Moreover, cross-sectional studies of incarcerated adults indicate that 20% to 30% meet diagnostic criteria for ADHD.3 These associations between childhood ADHD, oppositional defiant disorder, and conduct disorder and later criminal behavior beg the question of whether treatment of ADHD can reduce the severity of, or in some cases prevent, criminal behavior.

To adopt a precision medicine approach to ADHD medication selection, there is a need for prospective studies to identify and then validate clinical, genetic, and other biomarkers that index interindividual variability (Buitelaar et al, 2022). We have conducted several studies of treating parents and children with ADHD, and previously reported decreased response to stimulant dose for the homozygous 9/9 allele of DAT1 (Stein et al, 2014). This genotype has also been linked with shorter life expectancy and twice smoking rate (Barkley et al, 2019). Because most individuals respond positively to ADHD medications, clinical and genetic predictors of poor tolerability and nonresponse to stimulants (eg, DAT1, CES1) could guide selection and dosing strategies.

Background ADHD commonly co-occurs in children and parents. When ADHD is untreated in parents, it contributes to negative child developmental and treatment outcomes. Screening for parent and child ADHD co-occurrence in pediatric primary care may be an effective strategy for early identification and treatment. There is no data on whether this screening model can be implemented successfully and there exists limited guidance on how to effectively approach parents about their own ADHD in pediatric settings. Even greater sensitivity may be required when engaging with families living in urban, low SES communities due to systemic inequities, mistrust, and stigma. Methods The current pilot study described the first 6 months of implementation of a parent and child ADHD screening protocol in urban pediatric primary care clinics serving a large population of families insured through Medicaid. Parents and children were screened for ADHD symptoms at annual well-child visits in pediatric primary care clinics as part of standard behavioral health screening. Independent stakeholder group meetings were held to gather feedback on factors influencing the implementation of the screening and treatment strategies. Mixed methods were used to examine initial screening completion rates and stakeholder perspectives (i.e., parents, primary care office staff, pediatricians, and behavioral health providers) on challenges of implementing the screening protocol within urban pediatric primary care. Results Screening completion rates were low (19.28%) during the initial 6-month implementation period. Thematic analysis of stakeholder meetings provided elaboration on the low screening completion rates. Identified themes included: 1) divergence between provider enthusiasm and parent hesitation; 2) parent preference versus logistic reality of providers; 3) centering the experiences of people with marginalized identities; and 4) sensitivity when discussing parent mental health and medication. Conclusions Findings highlight the importance of developing flexible approaches to screening parent and child ADHD in urban pediatric health settings and emphasize the importance of cultural sensitivity when working with marginalized and under-resourced families. Trial registration NCT04240756 (27/01/2020).

Objective This study examined the distinctiveness of Attention Deficit Hyperactivity Disorder—Inattentive (ADHD-I) and ADHD in context of Sluggish Cognitive Tempo (ADHD + SCT) utilizing the Attention Network Test (ANT) and Continuous Performance Test (CPT) as external validators. Due to the SCT characteristics of being sluggish, spacey, and slow to arouse, we hypothesized that SCT behavioral descriptors would be uniquely related to alerting/arousal mechanisms that the ANT is uniquely designed to capture, and that ADHD symptoms would be more highly associated with cognitive control on the CPT. Method We examined associations between baseline ANT and CPT scores for N = 137 well-characterized, culturally and racially diverse youth with ADHD ( n = 107) either medication naïve or washed out prior to testing and typically developing controls ( n = 30) ages 6–17 years. Results Presence and severity of SCT were associated with ANT Alerting ( r 2 = −.291, p = .005), but not with ANT Orienting, ANT Executive Control, or any CPT measures. There was a distinct association between the presence and severity of ADHD inattention symptoms with CPT T -scores for Commission Errors ( r 2 = .282, p = .002), Omission Errors ( r 2 = .254, p = .005), Variability ( r 2 = .328, p < .001), and Hit Rate SE ( r 2 = .272, p = .002), but not with other CPT or any ANT domain measures. All associations remained significant after Bonferroni correction. Conclusions The small but enduring double dissociation, with ADHD-I symptom severity related to measures of cognitive and behavioral control measures on the CPT, and SCT symptom severity related to attentional processes underlying tonic arousal in preparation for cue detection on the ANT—provides the first objective evidence suggestive of partial neurocognitive independence of SCT from ADHD. Moreover, it points to possibly distinguishable neurobiological neurocognitive underpinnings of the two conditions.

Objective: ADHD is associated with suboptimal health behaviors including physical activity (PA). LEAP is a parent BMT group program enhanced to focus on health behaviors, integrated with mHealth technology. Little is known about implementing BMT via telemedicine "telegroups." Methods: Children ages 5 to 10 with ADHD and their caregiver wore activity trackers and participated in an 8 to 9 week parent BMT and social media group emphasizing PA, sleep, and screen use. A 7-day child accelerometer-wear and parent and teacher measures were completed pre- and post-group. Groups were in-person prior to the COVID-19 pandemic and in telegroup format during the pandemic. Results: Thirty-three families participated in person and 23 participated via virtual telegroup. Group attendance was superior for telegroup with equivalent satisfaction and skill use. Changes in health behavior and clinical outcomes were equivalent. Conclusions: LEAP is a feasible and novel BMT intervention that can be delivered in an accessible telegroup format with high participation and acceptability.

There is a robust literature of predominantly cross-sectional studies demonstrating an association between attention-deficit/hyperactivity disorder (ADHD) and sleep quality in childhood and adolescence, measured by subjective as well as objective measures, dimensional and categorical variables, and controlling for a wide range of confounders such as other disorders.1 Moreover, ADHD symptoms and sleep problems are independently associated with adverse functional outcome and quality of life.2 As a result, these are viewed as common and mutually exacerbating conditions, likely mediated by common neuropathways.3-5.