Core ADHD Symptoms Research Articles

Early Visual Foraging in Relationship to Familial Risk for Autism and Hyperactivity/Inattention

Objective: Information foraging is atypical in both autism spectrum disorders (ASDs) and ADHD; however, while ASD is associated with restricted exploration and preference for sameness, ADHD is characterized by hyperactivity and increased novelty seeking. Here, we ask whether similar biases are present in visual foraging in younger siblings of children with a diagnosis of ASD with or without additional high levels of hyperactivity and inattention. Method: Fifty-four low-risk controls (LR) and 50 high-risk siblings (HR) took part in an eye-tracking study at 8 and 14 months and at 3 years of age. Results: At 8 months, siblings of children with ASD and low levels of hyperactivity/inattention (HR/ASD-HI) were more likely to return to previously visited areas in the visual scene than were LR and siblings of children with ASD and high levels of hyperactivity/inattention (HR/ASD+HI). Conclusion: We show that visual foraging is atypical in infants at-risk for ASD. We also reveal a paradoxical effect, in that additional family risk for ADHD core symptoms mitigates the effect of ASD risk on visual information foraging.

Web-Based Intervention for Teachers of Elementary Students With ADHD: Randomized Controlled Trial

Objective: To test the acceptability, satisfaction, and effectiveness of a web-based intervention for teachers of elementary school–aged children with ADHD. Method: Elementary classroom teachers (N = 58), along with their students with ADHD, participated in a randomized controlled trial. The program consisted of six sessions that included evidence-based intervention strategies for reducing ADHD symptoms and impairment in the classroom setting. Teachers also had access to a moderated Discussion Board and an online ADHD coach. Questionnaire data were electronically collected from teachers and parents pre-intervention, post-intervention (6 weeks), and after an additional 6-week follow-up. Results: Intent-to-treat analyses found significant improvements based on teacher (but not parent) reports of core ADHD symptoms and impairment for the Teacher Help for ADHD treatment group. Teachers reported a high level of acceptability and satisfaction. Conclusion: Web-based ADHD interventions have the potential to reduce the barriers to treatment utilization and implementation that are common problems for school-based ADHD interventions.

Variation in Presentation, Diagnosis, and Management of Children and Adolescents With ADHD Across European Countries

Objective: To characterize differences in presentation, diagnosis, and management of children/adolescents with ADHD in six European countries. Method: Physicians abstracted clinical records for patients aged 6 to 17 years, diagnosed from 2004 to 2007 and treated for ≥2 years. Documentation included impairment due to core ADHD symptoms and additional ADHD symptoms/behaviors at diagnosis, diagnostic approach, and treatment modality. Results: Study included 779 patients treated by 340 physicians. Prevalence of ADHD subtypes (inattention, hyperactivity/impulsivity, or combined) was similar across countries. Mean scores for core and noncore symptom impairment varied and were highest in Italy and the United Kingdom. Variability was noted in diagnostic approach; 95% of physicians in the Netherlands used Diagnostic and Statistical Manual of Mental Disorders (4th edition) criteria versus 10% in Germany. Differences were reported for initial treatment modality, treatment switching, and physician-reported treatment outcomes. Conclusion: European countries varied in diagnostic approaches and practice management of children/adolescents with ADHD.

Effects of story mapping on third-grade students with Attention Deficit Hyperactivity Disorder

Abstract The purpose of this study was to examine the effects of story mapping on the reading comprehension scores, on-task behaviors, and attitudes of third- -grade students (N = 6) with ADHD. Students’ reading grade equivalencies were assessed before and after the study. The teacher-researcher compared two other achievement measures before and during story mapping to assess growth. The practical difference in scores as calculated with Cohen’s d revealed that story mapping was successful in improving students’ comprehension. On tests from the reading basal, students’ scores improved an average of 16.00%, while tests from a computerized reading program improved 20.00%. Students exhibited on-task behavior 79.33% of the time and positive attitudes 82.33% of the time during the intervention. The implications of this study are important in determining effective instructional strategies to promote the active engagement of students and combat the core symptoms of ADHD.

Methylphenidate improves the quality of life of children and adolescents with ADHD and difficult-to-treat epilepsies

ObjectiveComorbidity between difficult-to-treat epilepsies and ADHD is frequent and impacts negatively on quality of life. The commonly held (yet poorly substantiated) view that stimulants may worsen seizure control has prevented studies from evaluating the impact of such treatment in this population. Our aim was to study the effect of methylphenidate on the quality of life of children and adolescents with difficult-to-treat epilepsies and comorbid ADHD. MethodsThe study was an open-label, noncontrolled trial with intention-to-treat analysis following 30 patients for 6months. Subjects received methylphenidate following 3months of baseline, during which antiepileptic drugs (AEDs) were adjusted and epilepsy, ADHD, and quality-of-life variables were assessed. Multivariate regression analysis identified the main variables correlated with outcome. ResultsOnly one patient withdrew because of seizure worsening. Following methylphenidate introduction, doses were titrated up to 0.40–0.50mg/kg/day. A marked improvement in quality-of-life scores and a significant reduction in seizure frequency and severity were observed. Female sex, reduction of core ADHD symptoms, and tolerability to adequate doses of methylphenidate were significantly associated with improved quality-of-life scores. ConclusionThese preliminary data suggest that methylphenidate treatment is safe and effective in patients with ADHD and difficult-to-treat epilepsies, positively impacting on quality-of-life scores.

PP10.3 – 2259: Lisdexamfetamine in the children with ADHD

Objective Lisdexamfetamine (LDX) is a pro-drug that is converted into dexamfetamine and is proved effective in children and adults with ADHD. According to NICE guidelines, dexamfetamine should be considered in children and young people whose ADHD is unresponsive to a maximum tolerated dose of methylphenidate or atomoxetine. We studied the effectiveness of Lisdexamfetamine in the children with severe ADHD. Methods Children aged 6–16 years with ADHD, who had poor response to the first line medication, were monitored using ADHD IV rating scale and Clinical Global Impression (CGI) scale. Total 51 children had Lisdexamfetamine in 2013. 36 (70%) were males and 15 (30%) females. The mean age was 11 years. 41 children were followed up (80.3%). Following self-reported side effects, LDX was stopped in 9. During each follow up visit blood pressure, heart rate and BMI were monitored. Results Among the 32 children, the ADHD-IV rating scale when LDX was started was between 27 and 50 (median 41; Mode 39, 44) whereas CGI scale was between 4 and 7 (median 5, mode 5). At their first follow up, The ADHD IV rating scale ranged between 10 and 49 (median 26.5, mode 23) and CGI between 2 and 5 (median 3, mode 3 and 4). Using t test as well as Wilcoxon signed rank test, all children had significant reduction in both ADHD IV and CGI scales and had symptom improvement. (p Conclusion LDX was used as a second line treatment in a group of children with ADHD and co-morbid disorders in a busy community setting. It was tolerated by majority of patients. All children who continued with treatment reported improvement of core ADHD symptoms in comparison to previous treatment. Longer follow up is required to establish long term tolerability of treatment.

Cognitive behavioral therapy for adults with attention-deficit hyperactivity disorder: study protocol for a randomized controlled trial.

BackgroundAttention-deficit hyperactivity disorder (ADHD) is a mental disorder beginning in childhood, and about half of patients have symptoms lasting into adulthood. Adult ADHD causes various impairments of emotional, self-esteem, and executive function and life quality aspects. Furthermore, adverse outcomes include academic and occupational failures, traffic accidents and substance abuse, which would be a family and social burden. A combination of medication and psychotherapy is recommended as the treatment for adult ADHD, and cognitive behavioral therapy (CBT) has been validated mostly with evidence-based researches. However, there has been a lack of randomized controlled trials of CBT for patients in China. Moreover, booster sessions of CBT for other disorders have proven effective in reducing recurrence and improving long-term outcomes, which has not been investigated for adult ADHD. This study will testify to the effect of CBT and explore the efficacy of subsequent booster sessions on adult ADHD.Methods/DesignIt is a three-armed randomized controlled trial to evaluate the efficacy of 12 weeks of CBT based on the published and validated manual and its booster sessions. The 12 weeks of CBT will be conducted weekly and will end at the 12th week, and then the booster sessions will be conducted monthly and end at the 24th week. There are three randomized groups, including a CBT with booster sessions group, a CBT group and a waiting group. Participants are outpatients of the Peking University Sixth Hospital who are diagnosed as having adult ADHD. The Primary efficacy endpoints are the scores of ADHD core symptoms at 12 and 24 weeks. Secondary endpoints include emotion, executive function, self-esteem, life quality and functional magnetic resonance imaging (fMRI) data at different time points, and the change within every group will also be analyzed.DiscussionThis is the first study to explore the efficacy of booster sessions of CBT in adult ADHD as far as we know. The results might increase proof of efficacy of CBT for adult ADHD in China, and the results showing efficacy of the booster sessions would also benefit our clinical practice.Trial registrationCurrent Controlled Trials: NCT02062411, date of registration: 12 February 2014.

Mothers’ Parenting Styles and the Association with Family Coping Strategies and Family Adaptation in Families of Children with ADHD

The aim of this study was to determine how the parenting styles of mothers are associated with the coping strategies and adaptability of families with a child diagnosed with ADHD. Using a cross-sectional research design, data was collected from mothers representing 98 South African families with children diagnosed with ADHD. Significant positive correlations were found between dimensions of the mothers’ authoritative parenting style (connection, autonomy granting and regulation) and the re-evaluation and mobilization of family coping strategies. A regression analysis indicated medication, mothers’ connection and mothers’ regulation as the best predictor variables for family adaptation. The use of medication to help control core ADHD symptoms can benefit families. In order to improve outcomes for parents and children with ADHD, it is also recommended that mothers are taught authoritative parenting skills.

The effects of atomoxetine on emotional control in adults with ADHD: An integrated analysis of multicenter studies

PurposeTo investigate the effects of atomoxetine on emotional control in adults with ADHD. MethodsWe performed an integrated analysis using individual patient data pooled from three Eli Lilly-sponsored studies. An integrated analysis can be viewed as a meta-analysis of individual patient-level data, rather than study-level summary data. ResultsTwo populations were identified: a large sample of patients with pre-treatment baseline data (the “overall population”; n=2846); and a subset of these patients with placebo-controlled efficacy data from baseline to 10 or 12weeks after initiating treatment (the “placebo-controlled population”; n=829). At baseline, in the overall population, ∼50% of ADHD patients had BRIEF-AS (Behavior Rating Inventory of Executive Function-Adult Version Self-Report) Emotional control subscores between 21 and 30, compared with ∼10% of normative subjects in the BRIEF-A manual. At endpoint, in the placebo-controlled population, atomoxetine led to a small (effect size 0.19) but significant (P=0.013) treatment effect for emotional control. The effect size was 0.32 in patients with BRIEF-AS Emotional control scores>20 at baseline. Improvements in emotional control correlated with improvements in the core ADHD symptoms and quality-of-life. DiscussionAs deficient emotional control is associated with impaired social, educational and occupational functioning over and above that explained by core ADHD symptoms alone, improvements in emotional control may be clinically relevant. ConclusionAt baseline, adults with ADHD were more likely to have impaired emotional control than normative subjects. In the adult ADHD patients, atomoxetine treatment was associated with improvements in emotional control, as well as in core ADHD symptoms and quality-of-life.

Unmet needs associated with attention-deficit/hyperactivity disorder in eight European countries as reported by caregivers and adolescents: results from qualitative research.

IntroductionAttention-deficit/hyperactivity disorder (ADHD) is a neurobehavioral disorder characterized by inattention, impulsivity, and hyperactivity, the levels of which are inappropriately high for an individual’s developmental age.ObjectiveThe objective of this study was to explore the unmet needs of children/adolescents with ADHD and their caregivers in eight European countries.MethodsSemi-structured interviews with 38 caregivers of children/adolescents (aged 6–17 years) with ADHD and no or less serious comorbidities and 28 adolescents (aged 13–17 years) with ADHD and no or less serious comorbidities were conducted, audio-recorded, transcribed into English, and coded for analysis.ResultsCaregivers reported their own ADHD-related issues, including making personal accommodations, such as limiting activities and spending extra time/effort caring for their child/adolescent, social impacts, and strained relationships. Medication was generally considered helpful; however, most children experience core ADHD symptoms while on medication (reported by 88 % of caregivers and 100 % of adolescents). Adolescents often reported schoolwork difficulties (96 %) and peer issues (75 %), while caregivers reported school issues (84 %) and peer difficulties (79 %). Caregivers reported minimal ADHD education and community support. Caregivers (29 %) and adolescents (54 %) desired medication that better controlled symptoms but had concerns about being oversubdued. Caregivers reported concerns about adverse effects (21 %).ConclusionsEuropean caregivers of children/adolescents with ADHD identified multiple unmet needs, which persist despite treatment. Adolescents noted impacts on school and social interactions consistent with caregivers. Future research is needed to quantify the study findings, and, ultimately, ease the impact of ADHD on patients and their caregivers.Electronic supplementary materialThe online version of this article (doi:10.1007/s40271-014-0083-y) contains supplementary material, which is available to authorized users.

Nutritional supplements for the treatment of ADHD.

Polyunsaturated fatty acid supplementation appears to have modest benefit for improving ADHD symptoms. Melatonin appears to be effective in treating chronic insomnia in children with ADHD but appears to have minimal effects in reducing core ADHD symptoms. Many other natural supplements are widely used in the United States despite minimal evidence of efficacy and possible side effects. This review synthesizes and evaluates the scientific evidence regarding the potential efficacy and side effects of natural supplements and herbal remedies for ADHD. We provide clinicians with recommendations regarding their potential use and role in overall ADHD treatment.

Effects associated with on- and off-label stimulant treatment of core autism and ADHD symptoms exhibited by children with autism spectrum disorder

Objective: Families of children with autism spectrum disorder are barraged by different treatment options. Some of these options have the support of empirical evidence while others do not. Stimulant treatments are typically utilized to treat symptoms of ADHD indicating an on-label use of such treatment. Methods: This study examines the association of stimulant treatment with the on- (symptoms of ADHD) and off- (symptoms of ASD) label symptoms among children with ASD via a non-clinical, population-based sample. Results: Results indicate no significant association of stimulant treatment with a reduction of on- or off-label symptoms among children with ASD. Conclusion: Stimulant medications utilized in the treatment of DSM core symptoms of autism spectrum disorder would be considered an off-label use because there is limited evidence to support that stimulants are effective in treating core symptoms of ASD, which is supported by the results of the current study.

Working memory training in young children with ADHD: a randomized placebo‐controlled trial

Until now, working memory training has not reached sufficient evidence as effective treatment for ADHD core symptoms in children with ADHD; for young children with ADHD, no studies are available. To this end, a triple-blind, randomized, placebo-controlled study was designed to assess the efficacy of Cogmed Working Memory Training (CWMT) in young children with ADHD. Fifty-one children (5-7years) with a DSM-IV-TR diagnosis of ADHD (without current psychotropic medication) were randomly assigned to the active (adaptive) or placebo (nonadaptive) training condition for 25 sessions during 5 weeks. The compliance criterion (>20 sessions) was met for 47 children. The primary outcome measure concerned the core behavioural symptoms of ADHD, measured with the ADHD Rating Scale IV (ADHD-RS). Secondary outcome measures were neurocognitive functioning, daily executive functioning, and global clinical functioning. The influence of the increase in difficulty level (Index-Improvement) for the treatment group was also analysed. Clinical trial registration information - 'Working Memory Training in Young ADHD Children'; www.clinicaltrials.gov; NCT00819611. A significant improvement in favour of the active condition was found on a verbal working memory task (p=.041; adapted Digit Span WISC-III, backward condition). However, it did not survive correction for multiple testing. No significant treatment effect on any of the primary or other secondary outcome measurements was found. The Index-Improvement significantly contributed to ADHD-RS and the Behavior Rating Inventory of Executive Function, both rated by the teacher, but revealed no significant group difference. This study failed to find robust evidence for benefits of CMWT over the placebo training on behavioural symptoms, neurocognitive, daily executive, and global clinical functioning in young children with ADHD.

Differential effects of anxiety and depressive symptoms on working memory components in children and adolescents with ADHD combined type and ADHD inattentive type

Working memory (WM) deficits have been shown to be associated with core ADHD symptoms, worse academic achievement and peer-relationship problems. Internalizing symptoms, such as anxiety and depression, have also been associated with impaired WM performance. However, the association of anxiety and depression and WM performance remains unclear for children and adolescents with ADHD. Further, it is unknown how these comorbid conditions might affect WM performance in the two main ADHD subtypes. The association of anxiety and depression and the specific components of spatial (SWM) and verbal working memory (VWM) were examined in 303 children and adolescents with ADHD, combined type (ADHD-CT) and 77 ADHD, inattentive type (ADHD-IA) compared to 128 age- and gender-matched typically developing participants. The relationship between anxiety and depression and WM was assessed using multiple linear regression analyses and separate simple regression analyses. Higher levels of anxiety/depression were associated with (1) increased between-search errors in the typically developing participants alone, (2) a better strategy performance in the ADHD-CT group, and (3) a better spatial span performance in the ADHD-IA group. VWM was equally impaired in the ADHD-CT and ADHD-IA groups, independent of the levels of anxiety and depression. The results suggest that the effects of internalizing symptoms on WM differ in typically developing children and adolescents compared to those with ADHD. Further, high levels of anxiety and depression modified WM performance differently according to the specific ADHD subtypes. This might help explain contradictory findings observed in previous studies of mixed samples of participants with ADHD-CT and ADHD-IA.

Atomoxetine Improved Attention in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder and Dyslexia in a 16 Week, Acute, Randomized, Double-Blind Trial

The purpose of this study was to evaluate atomoxetine treatment effects in attention-deficit/hyperactivity disorder (ADHD-only), attention-deficit/hyperactivity disorder with comorbid dyslexia (ADHD+D), or dyslexia only on ADHD core symptoms and on sluggish cognitive tempo (SCT), working memory, life performance, and self-concept. Children and adolescents (10-16 years of age) with ADHD+D (n=124), dyslexia-only (n=58), or ADHD-only (n=27) received atomoxetine (1.0-1.4 mg/kg/day) or placebo (ADHD-only subjects received atomoxetine) in a 16 week, acute, randomized, double-blind trial with a 16 week, open-label extension phase (atomoxetine treatment only). Changes from baseline were assessed to weeks 16 and 32 in ADHD Rating Scale-IV-Parent-Version:Investigator-Administered and Scored (ADHDRS-IV-Parent:Inv); ADHD Rating Scale-IV-Teacher-Version (ADHDRS-IV-Teacher-Version); Life Participation Scale-Child- or Parent-Rated Version (LPS); Kiddie-Sluggish Cognitive Tempo (K-SCT) Interview; Multidimensional Self Concept Scale (MSCS); and Working Memory Test Battery for Children (WMTB-C). At week 16, atomoxetine treatment resulted in significant (p<0.05) improvement from baseline in subjects with ADHD+D versus placebo on ADHDRS-IV-Parent:Inv Total (primary outcome) and subscales, ADHDRS-IV-Teacher-Version Inattentive subscale, K-SCT Interview Parent and Teacher subscales, and WMTB-C Central Executive component scores; in subjects with Dyslexia-only, atomoxetine versus placebo significantly improved K-SCT Youth subscale scores from baseline. At Week 32, atomoxetine-treated ADHD+D subjects significantly improved from baseline on all measures except MSCS Family subscale and WMTB-C Central Executive and Visuo-spatial Sketchpad component scores. The atomoxetine-treated dyslexia-only subjects significantly improved from baseline to week 32 on ADHDRS-IV-Parent:Inv Inattentive subscale, K-SCT Parent and Teacher subscales, and WMTB-C Phonological Loop and Central Executive component scores. The atomoxetine-treated ADHD-only subjects significantly improved from baseline to Week 32 on ADHDRS-Parent:Inv Total and subscales, ADHDRS-IV-Teacher-Version Hyperactive/Impulsive subscale, LPS Self-Control and Total, all K-SCT subscales, and MSCS Academic and Competence subscale scores. Atomoxetine treatment improved ADHD symptoms in subjects with ADHD+D and ADHD-only, but not in subjects with dyslexia-only without ADHD. This is the first study to report significant effects of any medication on SCT. This study was registered at: http://clinicaltrials.gov/ct2/home, NCT00607919.

Assessment of ADHD Symptoms and the Issue of Cultural Variation: Are Conners 3 Rating Scales Applicable to Children and Parents With Migration Background?

Objective: The objective was to evaluate whether Conners 3 (Conners 3rd edition) ratings of ADHD symptoms are robust to distortion by cultural variation when applied to children with migration background living in Germany. Method: From 2010 to 2011, Conners 3 data (self-rating, parent rating, and teacher rating) of 243 children with Turkish migration background, aged 6 to 16 years, were collected in various German schools. Allocation of items to latent factors was tested with confirmatory analyses. Reliability and validity of resulting factors was calculated and influence of acculturation, gender, and age on rating-modalities was examined. Results: Confirmatory factor analyses showed high model fits for all rating-modalities. Resulting scales had good reliability and validity. There was a small influence of acculturation on parent ratings of oppositional defiant disorder but not on ADHD core symptoms. Conclusion: Conners 3 ratings seem to be robust against influences of cultural variation. Their German translation can be utilized for children with Turkish migration background without limitation.

Interference control in adult ADHD: No evidence for interference control deficits if response speed is controlled by delta plots

Several theoretical accounts assume that interference control deficits belong to the core symptoms of adult ADHD. However, findings of increased interference effects in adult ADHD patients compared with healthy adults may be confounded with the simultaneous finding of generally slower responses in the patient group. The current study compared the magnitude of the interference effect in the Stroop task between a group of adults with ADHD and a healthy adult control group in a procedure that accounted for differences in overall response speed by using delta plots. The amount of interference did not differ between patient and control group at comparable reaction time levels. These results challenge the conclusions of the previous studies, in that they indicate that interference control is not impaired in adult ADHD.

Limited Support for the Efficacy of Nonpharmacological Treatments for the Core Symptoms of ADHD

Limited Support for the Efficacy of Nonpharmacological Treatments for the Core Symptoms of ADHD

Systematic review of atomoxetine data in childhood and adolescent attention-deficit hyperactivity disorder 2009–2011: Focus on clinical efficacy and safety

Clinicians obtain critical prescribing knowledge from clinical papers and review articles. This is the first published systematic review of clinical atomoxetine data covering 2009-2011. We aim to update clinicians on current clinical atomoxetine data with specific reference to time of onset of efficacy and maximal efficacy. These data may allow critical analysis of comparative efficacy between atomoxetine and stimulant medications. A formal systematic review of atomoxetine data from January 2009-June 2011 was conducted. The search term used was "atomoxetine" in the English language. The search yielded 747 citations from which 106 are clinical data. This paper includes clinical efficacy and safety data and excludes quality-of-life and review papers. Atomoxetine has an onset of action within 4 weeks (possibly within 1 week in subsequent responders) but requires at least 12 weeks for full response to be demonstrated. Treatment-naïve cohorts (6-12 weeks) report effect sizes of 0.6-1.3. Using minimum 6-week clinical trial criteria, atomoxetine may demonstrate similar efficacy to methylphenidate comparing reduction in core ADHD symptoms in meta-analysis, although the diversity of the data makes interpretation complex. From epidemiological databases, cardiovascular and suicide-related events were similar to those seen in patients taking methylphenidate. Incremental response time to atomoxetine should be considered in the design of future comparative efficacy trials.

Behavioral Assessment of Core ADHD Symptoms Using the QbTest

Objective: Hyperactivity, one of the core symptoms of ADHD, has been mostly neglected in neuropsychological assessment of childhood ADHD. The neuropsychological Quantified behavior Test (QbTest) separately assesses all three core symptoms of ADHD on a behavioral level. Factor structure of the QbTest and its concurrent and discriminant validity are presented. Method: An exploratory factor analysis (n = 828 children) was performed. In a second sample (n = 102 children) a Multi-Trait-Multi-Method (MTMM) approach was used for validity analyses. Results: A three factorial model explained 76 % of the total variance, with the resulting QbTest factors significantly influenced by age and gender. The MTMM approach yielded promising results for discriminant, yet inconsistent findings for concurrent validity between the QbTest and another attention test as well as for Conners’ Parent and Teacher Rating Scales. Conclusion: Results indicate that the QbTest may be helpful for the behavioral assessment of childhood ADHD, yet further studies on its psychometric quality and clinical utility are needed.