Perceptions of adults with ADHD on pharmacological treatment initiation and subsequent adherence: a thematic analysis.

Treatment Controversies in Adult ADHD.

Can Guidelines Help Reduce the Medicalization of Early Childhood?

Review question/objective The objective of the systematic review is to identify and synthesize the best available evidence on how parents experience living with a child with attention deficit hyperactivity disorder (ADHD) including their experiences of ADHD health care services. The review questions are: How does living with a child with ADHD affect family life?What are the parental challenges of having a child with ADHD?How do parents experience collaboration with health care settings and professionals? Background Attention deficit hyperactivity disorder is the most prevalent mental disorder among children and adolescents worldwide, and the incidence of ADHD has increased in recent years.1 Attention deficit hyperactivity disorder in children is characterized by inattention, hyperactivity and impulsivity, and these characteristics are often present before the age of seven. The prevalence estimates for ADHD vary considerably worldwide due to demographic, cultural and socioeconomic characteristics of the population as well as the various criteria used for diagnosis. However, it is estimated that the prevalence in school children aged between five and 12 is 4-7%.2,3 Attention deficit hyperactivity disorder occurs in all socioeconomic groups, although it is more frequent in lower socioeconomic groups in society.2-4 Children with ADHD have care needs that reinforce a multimodal approach. They are often treated with medication which is supplemented with a variety of psychosocial and psycho educational interventions to improve their functioning.5 Furthermore, ADHD can be complicated by co-morbid conditions such as depression, anxiety and conduct disorders. Compared with the general population, ADHD is also associated with an increased prevalence of physical conditions including asthma, food allergy, epilepsy and severe headaches.2,8 Attention deficit hyperactive disorder often presents with challenging behavior and is associated with impairment in social, familial, emotional, academic and behavioral functioning.6,7 Attention deficit hyperactivity disorder may impact the lives of children and their families, for example, it affects practical and psychological aspects of daily life, school life and social life.6,7 The lives of families with children with ADHD can be influenced by many factors.9 Studies on parenting experiences show that parents find it challenging to raise and support the child.1,6 Findings indicate that the parents are struggling to maintain a bearable family life and to learn how to successfully handle their child.1,6 In addition, parents raising children with ADHD experience more emotional distress, stress and exhaustion than parents raising children without ADHD.1 Raising a child with ADHD also affects the families' social life as parents are worried how the child with ADHD will behave if they go on visits, holidays etc.9 Mental illness is associated with stigma, and living with a child with ADHD seems to have a significant impact on the families' experiences of stigma.10 Parenting a child with ADHD may cause experiences of social isolation, negative public views and sometimes the characteristics of the child with ADHD provoke negative reactions and intolerance from other parents or family members.9,10 Thus, the parents are concerned how society will judge a child diagnosed with ADHD, and they fear that the diagnosis may have a negative impact on their child's future opportunities.10 Although the majority of studies imply that raising a child with ADHD affects family lives negatively, studies report that the parents benefit from early identification and help and support from professionals.11 Some families develop strategies to cope with the problems related to their child's disorder.6,12 Parenting experiences of living with a child with ADHD include experiences of ADHD care and treatment.20 Children with ADHD are cared for and treated in various settings both in and outside of medical settings. Parents may be challenged by coordinating care and treatment as the diverse settings and professionals do not always tend to collaborate.14,15,20 A study estimates that as the rate of mental illness in the child population continues to increase, an extended use of collaboration with health professionals such as school psychology services, public health nursing, hospital psychiatry etc. is an important factor in providing high quality services.13 Treatment and care for children with mental health problems can involve between six to ten professionals across sectors.13 Studies reveal different perceptions regarding parents' collaboration with professionals. On one hand, parents of children with ADHD are grateful for the help and support from professionals to provide the best possible care for their children.1,4 On the other hand, parents experience barriers to treatment and care, as it is provided in diverse settings with numerous professionals involved.14,15 In addition, professionals and parents may conceptualize ADHD differently and have different perceptions of what collaboration entails.11 Studies show that parents lack directions and help from professionals to make decisions concerning medication.16-18 ADHD treatment and care may also be compromised by lack of continuity of care and if health professionals do not meet the families' individual emotional and educational needs.4,20 Family factors such as conflicts within the family and the psychopathology of the parents may also contribute to barriers in treatment and care.4,19 The literature indicates that parenting children with ADHD is influenced and challenged in different ways.1,20 However, diverse perspectives exist as how parenting a child with ADHD influences the families' daily life, how the parents manage raising the child, which factors parents find important and helpful factors and how parents experience ADHD care in diverse settings and the involvement with professionals across sectors. Studies find that the parents need more intensive support to help their child in the best possible way, and it is also recommended that professionals must be aware of the families' situations and their needs.1,11 An initial search in the databases of PubMed, CINAHL, JBIConnect+, Cochrane Library and PsycINFO showed that no systematic review on this topic exists or in progress currently. It is necessary to aggregate knowledge to further understand parenting experiences of living with a child with ADHD including their experiences of ADHD health care services to identify important and helpful factors in care and treatment. This may contribute to knowledge on how professionals can support the families in managing their situations. It may also contribute to the pertinent discussion on continuity of patient care and on how health care services ought to be organized to ensure the best possible care and treatment for children with ADHD and their parents.

Editorial Perspective: COVID-19, ADHD management and telehealth: uncertain path.

Attention deficit disorder/hyperactivity: a scientific overview

National Variation of ADHD Diagnostic Prevalence and Medication Use: Health Care Providers and Education Policies

The Northern Finnish Birth Cohort (NFBC) study of Attention Deficit Hyperactivity Disorder (ADHD) was initiated in 2001 to identify risk genes and gene–by–environmental interactions underlying ADHD in a population-based cohort of adolescents who have been followed prospectively since their birth in 1986. The cohort is drawn from northern Finland (pop. 630,000), where the population consists primarily of two groups—an early settlement and a late settlement. The late settlement descended from a small number of families (or founders) who migrated there in the 17th century and expanded locally. The small number of founders in a region that is fairly geographically isolated has resulted in a “population isolate” that is invaluable to genetic studies of single gene (i.e., monogenic) disorders as well as disorders which are thought to be due to several genes (i.e., polygenic). The first set of five papers on the NFBC study of ADHD was recently published in the December 2007 issue of the Journal of the American Academy of Child and Adolescent Psychiatry, and this article will summarize those detailed papers to present the main conclusions drawn about ADHD, based on one of the largest population-based studies of ADHD. Readers are directed to that journal for the methods, detailed results, and a more extensive discussion of the conclusions. The NFBC provides a unique opportunity to examine the developmental trajectory of ADHD in a social setting where medication is not the primary approach to treating ADHD. In fact, very few of the almost 457 (ADHD = 188, Controls = 269) adolescents assessed during the study had ever received any pharmacological treatment. Despite striking differences in treatment approaches between northern Finland and the United States, the clinical characteristics, psychiatric comorbidity, and cognitive deficits associated with ADHD are very much alike. Thus, one of the first major conclusions from this set of studies is that, despite the controversy regarding the validity of the ADHD diagnosis, ADHD is a clearly recognizable condition with a relatively stable prevalence worldwide. Using DSM–IV diagnostic criteria in a population-based cohort of adolescents (ages 16–18) in northern Finland, the prevalence is 8.5%. The clinical characteristics of ADHD in this population are strikingly similar to other ADHD samples drawn around the world with more boys than girls being affected, similar rates of psychiatric comorbidity, and similar rates of persistence of ADHD from childhood into adolescence (~2/3). Description of the ascertainment method and clinical characteristics of the sample were described in the paper by Smalley and colleagues (Smalley et al., 2007). One goal of the study was to examine ADHD symptoms within a large popu-

Effect of drugs on the risk of injuries in children with attention deficit hyperactivity disorder: a prospective cohort study

Adults with attention deficit hyperactivity disorder (ADHD) experience executive function (EF) impairments that affect their daily life and quality of life (QoL). Clinical guidelines recommend combining pharmacological and nonpharmacological treatments. The Cognitive-Functional Intervention for Adults (Cog-Fun A) is a metacognitive, occupation-based intervention that has shown preliminary efficacy, but more practice-based research is needed to evaluate its implementation. To examine (1) the effectiveness of the Cog-Fun A on QoL and EF of adults with ADHD and (2) the demographic and clinical predictors of reliable change on QoL postintervention and intervention adherence. Retrospective case series. Community. One hundred fifteen adults ages 19-70 yr (39.1% men). Participants received 24 1-hr weekly sessions addressing self-awareness of strengths and ADHD-associated executive deficits through education and analyses of individual occupational experiences, strategy acquisition, and implementation within an occupational goal attainment context. The Adult ADHD Quality-of-Life Scale, to assess QoL; and the Behavioral Rating Inventory of Executive Function-Adult Version (BRIEF-A), to assess EF. Among 107 participants, posttreatment scores showed significant improvements in all QoL domains and EFs. Clinically significant QoL changes occurred in 45% of the participants, with 34% meeting reliable change criteria. No demographic variables predicted these changes. Female gender, frequent pharmacological treatment, and lower baseline BRIEF-A scores predicted intervention completion. Cog-Fun A may offer an effective, metacognitive, occupation-based nonpharmacological treatment of adults with ADHD; however, further research is recommended. Plain-Language Summary: The Cognitive-Functional Intervention for Adults (Cog-Fun-A) may offer an effective metacognitive occupation-based nonpharmacological intervention for adults with attention deficit hyperactivity disorder (ADHD). Adults with ADHD often struggle with cognitive impairments that impede their ability to manage their life roles. Although treatments such as medications and therapies are available, there is a need for practical interventions that directly address daily life difficulties. This study aimed to examine whether the Cog-Fun-A intervention improves quality of life and cognitive functioning for adults with ADHD. The results showed that 107 of 115 participants completed the intervention and that 45% of the participants demonstrated clinically significant improvement. Women, frequent medication users, and those with better initial cognitive scores were more likely to complete the intervention. The Cog-Fun-A may offer an effective, function-based treatment for adults with ADHD, but more research is required.

Attention Deficit/Hyperactivity Disorders

Attention deficit hyperactivity disorder (ADHD) is a childhood neurological disorder. Studies have shown that children with ADHD are more prone to caries than those without. The study investigated children diagnosed with ADHD, both with and without pharmacological intervention, and the following: DMFT\dmft, plaque index (PI), mutans streptococci (MS) levels, lactobacilli (LB) levels, salivary flow, salivary buffer capacity, oral hygiene, and diet. DMFT/dmft index, PI, MS and LB levels, salivary flow, and salivary buffer capacity were examined in three groups of children: ADHD1-diagnosed with ADHD with no pharmacological intervention (N = 31), ADHD2-treated with medications for ADHD (N = 30), and a healthy control group (N = 30). Diet and oral health habits were assessed through questionnaires completed by parents. There were no differences in the DMFT/dmft index, MS and LB counts, salivary buffer capacity, and parent reported diet and oral health behavior between the three groups. Children with ADHD demonstrated a higher plaque index. Although children with ADHD did not report different diet and oral health behavior from children without ADHD, this group had significantly higher levels of plaque than the control group, which combined with hyposalivation may be a risk factor for caries at an older age. Medicated and non-medicated ADHD children were similar to control children in their caries rate, MS and LB counts, salivary buffer capacity, and diet and oral health behavior. They differed in the amount of plaque found on their teeth. As a group, ADHD children demonstrated hyposalivation compared with the control.

ABSTRACTIntroduction: Substance use disorder (SUD) is very common amongst patients with attention deficit hyperactivity disorder (ADHD). The two disorders share partially overlapping features and SUD in ADHD is characterized by an early age of onset, high likelihood of poly-substance use, increased risk of suicide attempts, more hospitalizations, and scarce treatment adherence.Areas covered: This paper reviews randomized active comparator-controlled or placebo-controlled trials evaluating the use of pharmacotherapy in patients with ADHD and SUD. The authors include open label and observational studies.Expert opinion: Stimulant and non-stimulant treatments should be used to aid ADHD symptomatology in patients with SUD. SUD seems to be less responsive, suggesting a relative independence of the two conditions. For this reason, the association of ADHD-specific drugs and SUD-treatments should be recommended in a large proportion of patients suffering from both disorders. The rate and the quality of ADHD response to specific pharmacological treatments is highly variable, depending on the dose and the duration of the treatment, the age of the patient, and the severity and the chronicity of addiction. Further research is necessary to explore the divergences in treatment response of different ADHD subtypes in different subtypes of SUD.

This study examines the relationship between parents' knowledge of attention-deficit hyperactivity disorder (ADHD) and opinions of treatment and their impact on enrolment in and adherence to both pharmacological and nonpharmacological interventions for children with ADHD. Participants in the study were the parents of 81 children who reached diagnostic criteria for ADHD and who were referred to a treatment study of ADHD involving stimulant medication and parent groups. The mothers completed a modified version of the ADHD Knowledge and Opinion Scale (AKOS) prior to receiving diagnostic feedback and prior to the families' decisions to participate in a 12-month randomized trial (medication [methylphenidate or placebo] and parent groups [training or support]). Treatment enrolment and adherence were monitored over the 12-month trial, and families who remained in the study at 12 months completed another modified AKOS. A higher level of knowledge of ADHD was found to be related to more favourable opinions of parent groups but not of medication. Moreover, parents who were more knowledgeable about ADHD were more likely to enroll in both pharmacological and nonpharmacological treatments. Adherence to pharmacological and nonpharmacological treatments was not predicted by parental knowledge of ADHD or opinions of the treatment. Parents' knowledge of ADHD and opinions of treatments play a significant role in enrollment in treatments for their children with ADHD. Providing information to parents regarding ADHD prior to offering treatment modalities could have a favourable impact on treatment enrollment and hence treatment adherence.

Children with nocturnal enuresis and attention deficit hyperactivity disorder: A separate entity?

Attention deficit hyperactivity disorder (ADHD) is a neurobiological disorder, which affects about 5.2% of school-aged children worldwide. Children with ADHD present teachers with a special challenge, since they interfere with teaching process and do not respond to typical classroom management techniques. In order to meet this challenge teachers must have accurate, up-to-date, information about the disorder so that they can respond to the needs of the student with ADHD. Studies that have examined teachers' beliefs and knowledge relating to ADHD highlighted the need for providing training to increase Greek teachers' knowledge and understanding of the disorder. Thus, the aims of the present study were: (a) to develop and evaluate brief ADHD training seminar for teachers; and (b) to investigate whether the training format (half-day versus two-day seminar) would have a differential effect on teachers' knowledge about ADHD. A total of 143 teachers formed the two sample groups; Group 1 (n=68) attended a half-day training (5 hours), and Group 2 (n=75) a two-day training (18 hours). Seminar topics included: (a) gaining basic knowledge about the symptoms, causes and natural history of ADHD, (b) understanding the key underlying cognitive deficits of the disorder and their impact on learning and behavior, (c) implementation of specific learning strategies for children with ADHD, (d) benefits and limitations of existing treatment approaches including the pharmacological treatment, and (e) available instruments for teachers that could inform their decision to refer the student to CAMHS for an assessment. A self-report ADHD Knowledge Questionnaire (ADHD-KQ), which covers four domains (clinical presentation, causes, cognitive deficits, interventions) was developed for the purpose of the present study, and was administered pre- and post-seminar. Teachers were generally knowledgeable about clinical presentation of ADHD, with more than 80% of the sample responding correctly to items pertaining to core symptoms. The internal consistency of the total ADHD-KQ scale measured by Cronbach's alpha coefficient was found to be good (0.89). The alpha coefficients for the sub-scales were acceptable (0.70 for the Symptoms/Diagnosis sub-scale, 0.73 for the Cognitive Deficits sub-scale, and 0.75 for the Intervention sub-scale), except for the Causes sub-scale, which was poor (0.59). In addition, each of the sub-scales showed a significant correlation with the total scales score (range r=0.66 to r=0.79), and there also was significant correlation between the four sub-scales (range r=0.39 to r=0.45). As expected, gaps in knowledge were identified, particularly in the area of causes, pharmacological treatment and cognitive deficits associated with ADHD. The results, using paired samples t tests, showed a highly significant increase in ADHD-KQ total and all sub-scale scores in both groups (p<0.001), indicating an overall improved knowledge about ADHD irrespective of the training format, i.e. half-day versus two-day training seminar. One-way MANOVA revealed significant difference between the two training seminars in mean pre-post difference sub-scale scores considered simultaneously. Subsequent univariate tests of between-subjects effects revealed that the group (training format) had a statistically significant effect on ADHD knowledge of symptoms sub-scale only [F(1,141)=10.46, p<0.01], with those who participated in the two-day training seminar having significantly higher mean pre-post difference scores as compared to teachers who attended the half-day training seminar (p<0.01). The present findings merit replication and, if confirmed in larger samples, have important implications for undergraduate curriculum development and training of practicing teachers, so that to overcome specific knowledge gaps and misconceptions with regards to ADHD. Future study should incorporate the use of classroom interventions and teaching strategies for students with ADHD, before and after brief training seminar, for a more thorough evaluation of its effectiveness.