Psychosocial Interventions for Attention Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis by the CADDRA Guidelines Work GROUP.

Multiple psychosocial interventions to treat ADHD symptoms have been developed and empirically tested. However, no clear recommendations exist regarding the utilization of these interventions for treating core ADHD symptoms across different populations. The objective of this systematic review and meta-analysis by the CADDRA Guidelines work Group was to generate such recommendations, using recent evidence. Randomized controlled trials (RCT) and meta-analyses (MA) from 2010 to 13 February 2020 were searched in PubMed, PsycINFO, EMBASE, EBM Reviews and CINAHL. Studies of populations with significant levels of comorbidities were excluded. Thirty-one studies were included in the qualitative synthesis (22 RCT, 9 MA) and 24 studies (19 RCT, 5 MA) were included in the quantitative synthesis. Using three-level meta-analyses to pool results of multiple observations from each RCT, as well as four-level meta-analyses to pool results from multiples outcomes and multiple studies of each MA, we generated recommendations using the GRADE approach for: Cognitive Behavioral Therapy; Physical Exercise and Mind-Body intervention; Caregiver intervention; School-based and Executive intervention; and other interventions for core ADHD symptoms across Preschooler, Child, Adolescent and Adult populations. The evidence supports a recommendation for Cognitive Behavioral Therapy for adults and Caregiver intervention for Children, but not for preschoolers. There were not enough data to provide recommendations for the other types of psychosocial interventions. Our results are in line with previous meta-analytic assessments; however, they provide a more in-depth assessment of the effect of psychosocial intervention on core ADHD symptoms.

A Review of Canadian Diagnosed ADHD Prevalence and Incidence Estimates Published in the Past Decade.

(1) Background: ADHD is recognized as one of the most common neurodevelopmental disorders. The worldwide prevalence of ADHD is estimated at 5.3%; however, estimates vary as a function of a number of factors, including diagnostic methods, age, sex and geographical location. A review of studies is needed to clarify the epidemiology of ADHD in Canada. (2) Methods: A search strategy was created in PubMed and adapted for MEDLINE and PsycINFO. Papers were included if they examined diagnosed ADHD prevalence and/or incidence rates in any region of Canada, age group and gender. A snowball technique was used to identify additional papers from reference lists, and experts in the field were consulted. (3) Results: Ten papers included in this review reported on prevalence, and one reported on incidence. One study provided an overall prevalence estimate across provinces for adults of 2.9%, and one study provided an overall estimate across five provinces for children and youth of 8.6%. Across age groups (1 to 24 years), incidence estimates ranged from 0.4% to 1.2%, depending on province. Estimates varied by age, gender, province, region and time. (4) Conclusions: The overall Canadian ADHD prevalence estimate is similar to worldwide estimates for adults. Most studies reported on prevalence rather than incidence. Differences in estimates across provinces may reflect the varying number of practitioners available to diagnose and prescribe medication for ADHD across provinces. To achieve a more comprehensive understanding of the epidemiology of ADHD in Canada, a study is needed that includes all provinces and territories, and that considers estimates in relation to age, gender, ethnicity, geographical region, socioeconomic status and access to mental healthcare coverage. Incidence rates need further examination to be determined.

The World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder.

BACKGROUND: Misconceptions about ADHD stigmatize affected people, reduce credibility of providers, and prevent/delay treatment. To challenge misconceptions, we curated findings with strong evidence base. METHODS: We reviewed studies with more than 2000 participants or meta-analyses from five or more studies or 2000 or more participants. We excluded meta-analyses that did not assess publication bias, except for meta-analyses of prevalence. For network meta-analyses we required comparison adjusted funnel plots. We excluded treatment studies with waiting-list or treatment as usual controls. From this literature, we extracted evidence-based assertions about the disorder. RESULTS: We generated 208 empirically supported statements about ADHD. The status of the included statements as empirically supported is approved by 80 authors from 27 countries and 6 continents. The contents of the manuscript are endorsed by 366 people who have read this document and agree with its contents. CONCLUSIONS: Many findings in ADHD are supported by meta-analysis. These allow for firm statements about the nature, course, outcome causes, and treatments for disorders that are useful for reducing misconceptions and stigma.

Primary Care Practitioner Training in Child and Adolescent Psychiatry (PTCAP): A Cluster-Randomized Trial.

OBJECTIVES: Rural primary care practitioners (PCPs) have a pivotal role to play in frontline pediatric mental health care, given limited options for referral and consultation. Yet they report a lack of adequate training and confidence to provide this care. The aim of this study was to test the effectiveness of the Practitioner Training in Child and Adolescent Psychiatry (PTCAP) program, which was designed to enhance PCPs' pediatric mental health care confidence. The program includes brief therapeutic skills and practice guidelines PCPs can use to address both subthreshold concerns and diagnosable conditions, themselves. METHODS: The study design was a pilot, cluster-randomized, multicenter trial. Practices were randomly assigned to intervention (n practices = 7; n PCPs = 42) or to wait-list control (n practices = 6; n PCPs = 34). The intervention involved 8 hr of training in practice guidelines and brief therapeutic skills for depression, anxiety, attention deficit hyperactivity disorder, and behavioral disorders with case discussion and video examples, while the control practiced as usual. A linear random-effects model controlling for clustering and baseline was carried out on the individual-level data to examine between-group differences in the primary (i.e., confidence) and secondary (i.e., attitude and knowledge) outcomes at 1-week follow-up. RESULTS: Findings were a statistically significant difference in the primary outcomes. Compared to the control group, the intervention group indicated significantly greater confidence in managing diagnosable conditions (d = 1.81) and general concerns (d = 1.73), as well as in making necessary referrals (d = 1.27) and obtaining consults (d = 0.74). While the intervention did not significantly impact secondary outcomes (attitudes and knowledge), regression analysis indicated that the intervention may have increased confidence, in part, by ameliorating the adverse impact of negative mental health care attitudes. CONCLUSION: PTCAP enhances PCPs' child/youth mental health care confidence in managing both general and diagnosable concerns. However, an 8-hr session focused on applying brief therapeutic skills was insufficient to significantly change attitudes and knowledge. Formal testing of PTCAP may be warranted, perhaps using more intensive training and including outcome assessments capable of determining whether increased PCP confidence translates to more effective management and better patient outcomes.

A Study Protocol for the "Practitioner Training in Child and Adolescent Psychiatry" Cluster-randomized Pilot Study.

BACKGROUND: Primary care providers (PCPs) are increasingly called upon to assist in meeting the growing demand for paediatric mental health care in Canada, yet they report inadequate training and confidence to do so. The Practitioner Training in Child and Adolescent Psychiatry (PTCAP) program was designed to fill this gap by teaching PCPs the skills needed to provide frontline care themselves, particularly in rural/remote regions where specialist resources are limited. This innovative educational intervention may improve paediatric mental health care capacity, but a pilot study is needed. METHODS: We designed a cluster randomized, controlled pilot of PTCAP. Random assignment to intervention or control (treatment-as-usual) will occur at the practice level. Participating PCPs (N=61) at sites randomized to intervention will receive eight hours of training in the use of practice guidelines and brief counseling techniques (i.e., common skills/elements) for addressing diagnosable conditions and more general, transdiagnostic concerns. Mental health care capacity at one-week post-intervention will be the primary outcome, assessed through self-report questionnaires of mental health care confidence, and through a more objective, observational assessment of trained skills. We will also examine retention of these skills at one-month follow-up. We expect use of trained common skills/elements to be associated with better child mental health outcomes on the Strengths and Difficulties Questionnaire (N = 250). DISCUSSION: As one of the first RCTs of its kind in Canada, this study will provide unique, preliminary evidence in regards to the feasibility and efficacy of the PTCAP intervention for enhancing rural, paediatric mental health care capacity.

CONTEXTE: Les prestataires de soins de première ligne (PSPL) sont de plus en plus sollicités pour aider à répondre à la demande croissante de soins de santé mentale pédiatriques au Canada, et pourtant, ils déplorent une formation et une confiance inadéquates pour ce faire. Le programme de Formation du médecin en psychiatrie de l'enfant et de l'adolescent (FMPEA) a été conçu pour combler cette lacune en enseignant aux PSPL les aptitudes nécessaires pour prodiguer eux-mêmes les soins de première ligne, particulièrement en région rurale/éloignée où les ressources de spécialistes sont limitées. Cette intervention éducative innovatrice peut améliorer la capacité des soins de santé mentale pédiatriques, mais une étude pilote est requise. MÉTHODES: Nous avons conçu un pilote contrôlé en grappes randomisées de la FMPEA. Cette assignation aléatoire de l'intervention ou du contrôle (traitement habituel) aura lieu au niveau de la pratique. Les PSPL participants (N = 61) aux endroits aléatoires de l'intervention recevront huit heures de formation en matière d'utilisation des lignes directrices de la pratique et de brèves techniques de consultation (c.-à-d., aptitudes/éléments communs) pour aborder les affections qui peuvent être diagnostiquées et des problèmes trans-diagnostiques plus généraux. À une semaine après l'intervention, la capacité des soins de santé mentale sera le principal résultat, évalué par des questionnaires auto-déclarés sur la confiance dans les soins de santé mentale, et par une évaluation observationnelle plus objective des aptitudes apprises. Nous examinerons également la rétention de ces aptitudes au suivi d'un mois. Nous prévoyons que l'utilisation des aptitudes/éléments communs appris soit associée à de meilleurs résultats de santé mentale des enfants au questionnaire des forces et des difficultés (N = 250). DISCUSSION: À titre d'un des premiers essais randomisés contrôlés (ERC) du genre au Canada, cette étude offrira des données probantes préliminaires uniques à l'égard de la faisabilité et de l'efficacité de l'intervention de FMPEA pour améliorer la capacité des soins de santé mentale pédiatriques en milieu rural.

Evaluating Training Programs for Primary Care Providers in Child/Adolescent Mental Health in Canada: A Systematic Review.

INTRODUCTION: The need for child/adolescent mental health care in Canada is growing. Primary care can play a key role in filling this gap, yet most providers feel they do not have adequate training. This paper reviews the Canadian literature on capacity building programs in child and adolescent psychiatry for primary care providers, to examine how these programs are being implemented and evaluated to contribute to evidence-based initiatives. METHODS: A systematic literature review of peer-reviewed published articles of capacity building initiatives in child/adolescent mental health care for primary care practitioners that have been implemented in Canada. RESULTS: Sixteen articles were identified that met inclusion criteria. Analysis revealed that capacity building initiatives in Canada are varied but rigorous evaluation methodology is lacking. Primary care providers welcome efforts to increase mental health care capacity and were satisfied with the implementation of most programs. DISCUSSION: Objective conclusions regarding the effectiveness of these programs to increase mental health care capacity is challenging given the evaluation methodology of these studies. CONCLUSION: Rigorous evaluation methods are needed to make evidence-based decisions on ways forward to be able to build child/adolescent mental health care capacity in primary care. Outcome measures need to move beyond self-report to more objective measures, and should expand the measurement of patient outcomes to ensure that these initiative are indeed leading to improved care for families.

INTRODUCTION: Le besoin de soins de santé mentale pour les enfants/adolescents s'accroît au Canada. Les soins de première ligne peuvent jouer un rôle clé pour combler ces besoins croissants, et pourtant, la plupart des prestataires de soins ne croient pas avoir de formation adéquate. Cet article examine la littérature canadienne sur les programmes de renforcement des capacités en pédopsychiatrie pour les prestataires de soins de première ligne, afin d'examiner comment ces programmes sont mis en oeuvre et évalués pour contribuer aux initiatives fondées sur les données probantes. MÉTHODES: Une revue systématique de la littérature et des articles révisés par les pairs publiés sur les initiatives de renforcement des capacités en soins de santé mentale aux enfants/adolescents pour les prestataires de soins de première ligne qui ont été mises en oeuvre au Canada. RÉSULTATS: Seize articles ont été repérés qui satisfaisaient aux critères d'inclusion, L'analyse a révélé que les initiatives de renforcement des capacités au Canada sont variées mais qu'il leur manque une méthodologie d'évaluation rigoureuse. Les prestataires de soins de première ligne acceptent volontiers les initiatives en vue d'accroître leur capacité en matière de soins de santé mentale et étaient satisfaits de la mise en oeuvre de la plupart des programmes. DISCUSSION: Des conclusions objectives sur l'efficacité de ces programmes de renforcement des capacités en soins de santé mentale sont difficiles étant donné la méthodologie d'évaluation de ces études. CONCLUSION: Des méthodes d'évaluation rigoureuses sont nécessaires pour prendre des décisions fondées sur les données probantes à l'égard des moyens de renforcer les capacités des soins de santé mentale pour enfants/adolescents dans les soins de première ligne. Les mesures des résultats doivent aller plus loin que l'auto-déclaration et adopter des mesures plus objectives, et devraient étendre la mesure des résultats des patients pour faire en sorte que ces initiatives mènent vraiment à de meilleurs soins pour les familles.

Canadian Rural/Remote Primary Care Physicians Perspectives on Child/Adolescent Mental Health Care Service Delivery.

INTRODUCTION: Primary Care Physicians (PCP) play a key role in the recognition and management of child/adolescent mental health struggles. In rural and under-serviced areas of Canada, there is a gap between child/adolescent mental health needs and service provision. METHODS: From a Canadian national needs assessment survey, PCPs' narrative comments were examined using quantitative and qualitative approaches. Using the phenomenological method, individual comments were drawn upon to illustrate the themes that emerged. These themes were further analyzed using chi-square to identify significant differences in the frequency in which they were reported. RESULTS: Out of 909 PCPs completing the survey, 39.38% (n = 358) wrote comments. Major themes that emerged were: 1) psychiatrist access, including issues such as long waiting lists, no child/adolescent psychiatrists available, no direct access to child/adolescent psychiatrists; 2) poor communication/continuity, need for more systemized/transparent referral processes, and need to rely on adult psychiatrists; and, 3) referral of patients to other mental health professionals such as paediatricians, psychologists, and social workers. CONCLUSIONS: Concerns that emerged across sites primarily revolved around lack of access to care and systems issues that interfere with effective service delivery. These concerns suggest potential opportunities for future improvement of service delivery. IMPLICATIONS: Although the survey only had one comment box located at the end, PCPs wrote their comments throughout the survey. Further research focusing on PCPs' expressed written concerns may give further insight into child/adolescent mental health care service delivery systems. A comparative study targeting urban versus rural regions in Canada may provide further valuable insights.

INTRODUCTION: Les médecins de soins de première ligne (MSPL) jouent un rôle essentiel dans la reconnaissance et la prise en charge des problèmes de santé mentale des enfants/adolescents. Dans les régions rurales et sous-desservies du Canada, il y a un écart entre les besoins de santé mentale des enfants/adolescents et la prestation de services. MÉTHODES: Tirés d'un sondage canadien national évaluant les besoins, les commentaires narratifs des MSPL ont été examinés à l'aide d'approches quantitatives et qualitatives. Au moyen de la méthode phénoménologique, les commentaires individuels ont servi à illustrer les thèmes dégagés. Ces thèmes ont ensuite été analysés avec le chi-carré afin d'identifier les différences significatives de la fréquence à laquelle ils étaient mentionnés. RÉSULTATS: Sur les 909 MSPL qui ont répondu au sondage, 39,38% (n = 358) ont écrit des commentaires. Les thèmes majeurs qui se sont dégagés étaient: 1) l'accès aux psychiatres, notamment des questions comme les longues listes d'attente, pas de pédopsychiatres disponibles, pas d'accès direct aux pédopsychiatres; 2) mauvaise communication/continuité, besoin de processus plus nombreux d'aiguillage systémique/transparent, et besoin de consulter des psychiatres pour adultes; 3) adresser les patients à d'autres professionnels de la santé comme les pédiatres, les psychologues et les travailleurs sociaux. CONCLUSIONS: Les préoccupations soulevées dans les divers centres s'articulaient autour de l'accès aux soins et des problèmes des systèmes qui empiètent sur la prestation efficace de services. Ces préoccupations suggèrent des possibilités pour l'amélioration future de la prestation de services. Implications: Bien que le sondage n'ait offert qu'un espace pour les commentaires à la fin, les MSPL ont écrit leurs commentaires sur tout le sondage. D'autres recherches portant sur les commentaires écrits des MSPL peuvent offrir d'autres idées sur les systèmes de prestation de services de santé mentale aux enfants/adolescents Une étude comparative ciblant les régions urbaines par rapport aux régions rurales du Canada peut fournir un apport valable.

Reflection training improves executive function in preschool-age children: behavioral and neural effects.

To assess the role of reflection in executive function, preschool-age children who perseverated (failed) on a pre-training version of the Dimensional Change Card Sort (DCCS) were given training with a different version (different stimuli) in which they were provided with corrective feedback and taught to reflect on the conflicting rule representations involved in the task. In Exp. 1, reflection training was based closely on Kloo and Perner (2003). Exp. 2 used a shortened (15min) version of the training protocol. In Exp. 3, this version of reflection training was compared to corrective feedback alone or mere practice with the task (without feedback). In all 3 experiments, children who received reflection training showed substantial improvements in performance on the pre-training version of the DCCS, whereas children in control conditions did not. In Exp. 3, these improvements were accompanied by a reduction from pre- to post-training in the amplitude of the N2 component of the ERP, an index of conflict detection. Results suggest not only that EF can be trained using a brief intervention targeting reflection, but also that training-related improvements in performance are associated with the down-regulation of ACC-mediated conflict detection. Implications for education are discussed.

N2 amplitude as a neural marker of executive function in young children: an ERP study of children who switch versus perseverate on the Dimensional Change Card Sort.

To explore the neurocognitive mechanisms underlying individual differences in executive function during the preschool years, high-density electroencephalography (EEG) was used to record event-related potentials (ERPs) from 99 children (between 35 and 54 months of age) during performance on the Dimensional Change Card Sort (DCCS), a widely used measure of executive function in which participants are required to sort bivalent stimuli first by one dimension and then by another. ERP analyses comparing children who switched flexibly (passed) to those who perseverated on post-switch trials (failed) focused on the N2 component, which was maximal over fronto-central sites. N2 amplitude was smaller (less negative) for children who passed the DCCS than for children who failed, suggesting that the N2, often associated with conflict monitoring, may serve as a neural marker of individual differences in executive function. Implications for learning and education are discussed.

Attitudes to the right- and left: frontal ERP asymmetries associated with stimulus valence and processing goals.

We used dense-array event-related potentials (ERP) to examine the time course and neural bases of evaluative processing. Participants made good vs. bad (evaluative) and abstract vs. concrete (nonevaluative) judgments of socially relevant concepts (e.g., "murder," "welfare"), and then rated all concepts for goodness and badness. Results revealed a late positive potential (LPP) beginning at about 475 ms post-stimulus and maximal over anterior sites. The LPP was lateralized (higher amplitude and shorter latency) on the right for concepts later rated bad, and on the left for concepts later rated good. Moreover, the degree of lateralization for the amplitude but not the latency was larger when participants were making evaluative judgments than when they were making nonevaluative judgments. These data are consistent with a model in which discrete regions of prefrontal cortex (PFC) are specialized for the evaluative processing of positive and negative stimuli.