Co-Occurring Psychopathology Moderates Social Skills Improvement in a Randomized Controlled Trial of a Collaborative School-Home Intervention for Children with ADHD.

OBJECTIVE: Children with ADHD often exhibit marked impairment in their social skills, but evidence-based psychosocial interventions for ADHD have shown limited efficacy in remediating these deficits. Co-occurring psychopathology exacerbates social deficits in children with ADHD and is a plausible moderator of treatment response. To identify factors contributing to variable social skills treatment response, we examined co-occurring externalizing, depression, and anxiety symptoms as moderators of social skills outcomes in a randomized controlled trial of the Collaborative Life Skills (CLS) program, an evidence-based collaborative school-home ADHD intervention. METHOD: Participants were 159 children with ADHD (M age = 8.35 years, 28.3% female) at 27 schools in an urban public school district. Twenty-three schools were randomly assigned to CLS or usual services, with an additional four schools assigned to Spanish-adapted CLS or usual services. Multi-informant measures of co-occurring psychopathology and social skills were collected at baseline and post-treatment. RESULTS: Parent-rated externalizing and depression symptoms moderated treatment effects on social skills, whereby higher symptomatology in each domain was unrelated to social skills improvement in the CLS group but predicted worsening social skills in response to usual services. In contrast, teacher-rated anxiety moderated treatment effects on social skills, whereby higher anxiety predicted greater social skills improvement in response to CLS but was unrelated to social skills outcomes following usual services. CONCLUSIONS: Findings reflect novel evidence that child psychopathology domains exhibit unique moderating effects on social skills treatment response in children with ADHD. We discuss implications for optimizing evidence-based interventions to target social impairment in this population.

Learning Disorder Confers Setting-Specific Treatment Resistance for Children with ADHD, Predominantly Inattentive Presentation.

Attention deficit/hyperactivity disorder-predominantly inattentive presentation (ADHD-I) and specific learning disorder (SLD) are commonly co-occurring conditions. Despite the considerable diagnostic overlap, the effect of SLD comorbidity on outcomes of behavioral interventions for ADHD-I remains critically understudied. The current study examines the effect of reading or math SLD comorbidity in 35 children with comorbid ADHD-I+SLD and 39 children with ADHD-I only following a behavioral treatment integrated across home and school (Child Life and Attention Skills [CLAS]). Pre- and posttreatment outcome measures included teacher-rated inattention, organizational deficits, and study skills and parent-rated inattention, organizational deficits, and homework problems. A similar pattern emerged across all teacher-rated measures: Children with ADHD-I and comorbid ADHD-I+SLD did not differ significantly at baseline, but between-group differences were evident following the CLAS intervention. Specifically, children with ADHD-I and comorbid ADHD-I+SLD improved on teacher-rated measures following the CLAS intervention, but children with ADHD-I only experienced greater improvement relative to those with a comorbid SLD. No significant interactions were observed on parent-rated measures-all children improved following the CLAS intervention on parent-rated measures, regardless of SLD status. The current results reveal that children with ADHD-I+SLD comorbidity benefit significantly from multimodal behavioral interventions, although improvements in the school setting are attenuated significantly. A treatment-resistant fraction of inattention was identified only in the SLD group, implying that this fraction is related to SLD and becomes apparent only when behavioral intervention for ADHD is administered.

Predictors of Response to Behavioral Treatments Among Children With ADHD-Inattentive Type.

The goal of the study was to examine baseline characteristics-child gender, IQ, age, internalizing problems, symptoms of hyperactivity/impulsivity (HI), oppositional defiant disorder, and sluggish cognitive tempo, and parent income, education, attention deficit/hyperactivity disorder (ADHD) severity, and anxiety/depression (A/D)-associated with response to behavioral treatments for ADHD, predominantly inattentive type. We employed data from 148 children (M = 8.7 years), 58% male, and 57% Caucasian in a randomized clinical trial. Positive treatment response was defined as (a) 5 or fewer inattentive symptoms and (b) a decrease of at least 3 inattentive symptoms from baseline to posttreatment. Child HI, parental A/D, and child IQ were associated with positive response, as follows: Child HI had a main effect in which it was negatively associated with treatment response (36% with 2 or more HI symptoms were positive responders vs. 59% of those with 1 or no symptoms) that was qualified by parental A/D and child IQ. When children had 2 or more symptoms of HI and higher parental A/D, positive response rate was low at 25%; when children had 2 or more symptoms of HI, low parental A/D, and an IQ of 105 or higher, positive response rate was 85%. Furthermore, the group with the poorest response rate (25%) had parents who self-reported greater ADHD severity, and the group with a relatively good rate of positive response (59%) had the lowest number of oppositional defiant disorder symptoms. Likelihood of positive response to our behavioral treatment for ADHD-I is dependent on child and parent factors.

Parent Adherence in Two Behavioral Treatment Strategies for the Predominantly Inattentive Presentation of ADHD.

We examined the effects of parent adherence on child outcomes in two treatment strategies for the Predominantly Inattentive Presentation of attention deficit/hyperactivity disorder (ADHD-I): behavioral parent training adapted for ADHD-I (Parent-Focused Therapy [PFT]) and a multicomponent intervention that combined PFT, a child life skills group, and a classroom intervention (Child Life and Attention Skills Program [CLAS]). In a 2-site randomized controlled trial, 199 children (7-11 years of age) were randomized to PFT (n = 74), CLAS (n = 74), or treatment as usual (n = 51). Parent adherence was rated separately by parents and clinicians. Child outcomes included ADHD-I symptoms and parent- and teacher- rated impairment social, organizational, and home impairment. Results from multiple regression analyses utilizing a composite of parent and clinician ratings showed that parent adherence predicted improvement in all 3 parent-rated child impairment outcomes and no teacher-rated outcomes in the PFT treatment group. Adherence ratings did not predict any parent- or teacher-rated outcomes in the CLAS treatment group and did not predict ADHD symptom change in either treatment condition. These findings suggest that when parents are solely responsible for teaching and reinforcing new child skills and behaviors (as in PFT), their adherence to the assigned intervention may be especially important for improvement at home. It may be less critical in multicomponent interventions, like CLAS, where the responsibility for teaching new child skills is shared among parents, teachers, and child group clinicians. Parent adherence does not appear to impact child improvement in the school setting.

Correction to: Influences to ADHD Problem Recognition: Mixed-Method Investigation and Recommendations to Reduce Disparities for Latino Youth.

The original version of this article unfortunately contained a mistake. The co-author, Dr. Araujo's name and the affiliation for Dr. Pfiffner was incorrect in the original version of the article. The correct information is given below.

Influences to ADHD Problem Recognition: Mixed-Method Investigation and Recommendations to Reduce Disparities for Latino Youth.

ADHD problem recognition serves as the first step of help seeking for ethnic minority families, such as Latinos, who underutilize ADHD services. The current mixed-method study explores underlying factors influencing recognition of ADHD problems in a sample of 159 school-aged youth. Parent-teacher informant discrepancy results suggest that parent ethnicity, problem domain, and child age influence ADHD problem recognition. Emerging themes from semi-structured qualitative interviews/focus groups conducted with eighteen Spanish-speaking Latino parents receiving school-based services for attention and behavior concerns support a range of recognized ADHD problems, beliefs about causes, and reactions to ADHD identification. Findings provide recommendations for reducing disparities in ADHD problem recognition and subsequent help seeking.

Cost-Effectiveness of a Behavioral Psychosocial Treatment Integrated Across Home and School for Pediatric ADHD-Inattentive Type.

We conducted a cost-effectiveness analysis (CEA) of two behavioral psychosocial interventions for children with ADHD-inattentive type: Child Life and Attention Skills (CLAS) program and parent-focused treatment (PFT) compared to community-based treatment as usual (TAU). The CEA evaluated cost per ADHD case resolved measured by parent and teacher reports of ADHD inattentive symptoms. Total cost per patient for CLAS, PFT, and TAU were $1559, $710, and $0. CLAS, the costliest treatment, was more effective than PFT and TAU. The incremental cost-effectiveness ratios (ICER) per disordered case resolved are: $3997 for CLAS versus TAU, $3227 for PFT versus TAU, and $4994 for CLAS versus PFT. PFT is the more cost-effective option based on initial CEA. However, CLAS may be comparably cost-effective by streamlining the model, which resulted in an ICER of $29 compared to PFT. Notably, cost for CLAS is substantially below the annual cost for unresolved ADHD.

Parental Cognitive Errors Mediate Parental Psychopathology and Ratings of Child Inattention.

We investigate the Depression-Distortion Hypothesis in a sample of 199 school-aged children with ADHD-Predominantly Inattentive presentation (ADHD-I) by examining relations and cross-sectional mediational pathways between parental characteristics (i.e., levels of parental depressive and ADHD symptoms) and parental ratings of child problem behavior (inattention, sluggish cognitive tempo, and functional impairment) via parental cognitive errors. Results demonstrated a positive association between parental factors and parental ratings of inattention, as well as a mediational pathway between parental depressive and ADHD symptoms and parental ratings of inattention via parental cognitive errors. Specifically, higher levels of parental depressive and ADHD symptoms predicted higher levels of cognitive errors, which in turn predicted higher parental ratings of inattention. Findings provide evidence for core tenets of the Depression-Distortion Hypothesis, which state that parents with high rates of psychopathology hold negative schemas for their child's behavior and subsequently, report their child's behavior as more severe.

Parenting Mediates Symptoms and Impairment in Children With ADHD-Inattentive Type.

The current study investigates potential pathways between inattentive symptom severity, positive and negative parenting practices, and functional impairment (i.e., academic, social, and home impairment) in a sample of children diagnosed with attention-deficit/hyperactivity disorder, Predominantly Inattentive Type (ADHD-I). Participants included 199 children and their parents and teachers enrolled in a randomized clinical trial investigating the efficacy of an integrated psychosocial intervention for children with ADHD-I. Boys constituted slightly more than half the sample; children averaged 8.6 years of age (range = 7-11) and were from varied ethnic/racial backgrounds. As part of the initial screening and assessment procedures, parents and teachers completed questionnaires assessing child behavior and parent/family functioning. Results supported both main effects of symptoms and parenting on impairment, as well as a mediational path between symptoms and impairment via parenting, as observed by parents in the home setting. Specifically, higher severity of inattention was associated with higher rates of homework, social, and home impairment. Negative parenting contributed to homework and home impairment, and positive and negative parenting contributed to social impairment, incrementally above and beyond the impact of inattention symptom severity alone. Negative parenting partially mediated the relationship between inattentive symptom severity and impairment, such that higher rates of inattention were associated with higher rates of negative parenting, which in turn was associated with higher rates of homework, social, and home impairment. Results provide support for underlying mechanisms for associations between symptoms and impairment in children with ADHD-I and identify potential intervention targets to improve impairment experienced by these children.

Additive effects of parent adherence on social and behavioral outcomes of a collaborative school-home behavioral intervention for ADHD.

The present study evaluated the impact of the Collaborative Life Skills Program (CLS), a novel school-home psychosocial intervention, on social and behavioral impairments among children with attention and behavior problems. Fifty-seven ethnically/racially diverse children (70 % boys) with attention and/or behavior problems in the second through fifth grades participated in a pilot study. Ten school-based mental health professionals were trained and then implemented the intervention at their respective schools. Children significantly improved from pre- to post-treatment on parent, teacher, and report card ratings of children's social and behavioral functioning. Treatment improvements were consistent for children with and without co-occurring disruptive behavior problems. The impact of the intervention was enhanced when parents used the intervention strategies more regularly, according to both clinicians' and parents' reports. Findings support the emphasis of CLS on coordinating intervention strategies across contexts to facilitate the generalization of treatment-related improvements in social and behavioral functioning.

Parental Cognitions, Treatment Engagement, and Child Outcomes of ADHD Behavioral Treatment among Asian American Families.

Asian American (AA) families remain critically underrepresented in clinical trials for ADHD interventions. Little is known about AA families' engagement in and outcomes of behavioral treatment (BT). Comparing AA families to other minoritized (OM) families and White families, this study examined parental cognitions, treatment engagement, and child outcomes of BT for ADHD inattentive type (ADHD-I). Path analyses were conducted utilizing data from a randomized controlled trial of BT for ADHD-I (N = 199 children, ages 7-11). Racial/ethnic differences in pretreatment parental self-competence and treatment expectations were examined for AA (n = 29) compared to OM (n = 35) and White (n = 135) parents. Two additional path models were conducted to examine the relations among race/ethnicity, pretreatment parental cognitions, treatment engagement, and posttreatment child outcomes. Direct effects of race/ethnicity and parental cognitions on posttreatment child outcomes as well as their indirect effects via treatment engagement were estimated. At pretreatment, AA parents endorsed lower parental self-competence and treatment expectations compared to OM and White parents. At posttreatment, AA parents reported fewer improvements in ADHD symptoms than White parents and lower global psychosocial improvement than OM parents. For all parents, treatment expectations positively predicted parent- and observer-rated treatment engagement, which in turn predicted child global psychosocial improvement. Path analyses indicated that the relationship between treatment expectations and posttreatment child global improvement was fully mediated by treatment engagement. These findings suggest that treatment expectations impede AA parents' engagement and success in BT. Implications for cultural adaptations of BT to improve AA families' treatment experience are discussed.

Emotion Regulation and Organizational Skills in Children With ADHD Symptoms Are Associated With Behavioral Parent Training Adherence.

OBJECTIVE: Behavioral parent training (BPT) is a well-established treatment for ADHD; however, treatment response is variable. Consistency in parent skill use during BPT is known to influence child outcomes post-treatment, while less research has focused on specific child factors that may be impacting parent skill utilization during treatment. The current study examined associations between child organizational skills and emotion dysregulation (ED) with parent treatment adherence during BPT and post-treatment child impairment. METHOD: Parents of 72 children (Mage = 8.31) with ADHD symptoms and impairment participated in BPT which was embedded in a 12-week, multicomponent, school-based intervention for children delivered by school mental health clinicians. Outcomes included parent treatment adherence and child improvements in global impairment post-treatment. RESULTS: Greater pre-treatment child organizational problems were associated with less parent treatment adherence regardless of ADHD symptom severity. Worse pre-treatment child ED was associated with more impairment post-treatment regardless of ADHD symptom severity whereas the effects of child ED on parent treatment adherence were moderated by child ADHD symptom severity. CONCLUSION: The current study suggests that pre-treatment child ED and organizational difficulties impact parent treatment adherence to behavioral interventions targeting ADHD symptoms, potentially in unique ways, and should be considered in future BPT treatment studies.

Negative social preference in relation to internalizing symptoms among children with ADHD predominantly inattentive type: girls fare worse than boys.

Despite distinct peer difficulties, less is known about the peer functioning of children with attention-deficit/hyperactivity disorder (ADHD) predominantly inattentive type (ADHD-I) in comparison to the peer functioning of children with ADHD combined type. Our purpose was to examine whether child sex moderated the relations between negative social preference and internalizing/externalizing problems in children with ADHD-I. Participants included 188 children diagnosed with ADHD-I (110 boys; ages 7-11; 54% Caucasian). Teacher ratings of the proportion of classmates who "like/accept" and "dislike/reject" the participating child were used to calculate negative social preference scores. Children, parents, and teachers provided ratings of anxious and depressive symptoms, and parents and teachers provided ratings of externalizing problems. Boys and girls did not differ on teachers' negative social preference scores. As hypothesized, however, the relation between negative social preference and internalizing symptoms was moderated by sex such that negative social preference was consistently and more strongly associated with internalizing symptoms among girls than in boys. In terms of externalizing problems, negative social preference was associated with teacher (but not parent) ratings, yet no moderation by child sex was found. Negative social preference is associated with teacher-report of externalizing problems for both boys and girls with ADHD-I, whereas negative social preference is consistently associated with girls' internalizing symptoms across child, parent, and teacher ratings. Implications for future research and interventions are discussed.

Integrating Treatment for Maternal Depression and Young Children's Behavior Problems.

It is important to consider reciprocal associations between maternal and offspring mental health problems during early childhood. Existing interventions often focus narrowly on either adult or child mental health, missing the opportunity for holistic care. We describe the rationale and development of a pilot randomized clinical trial that explores their integration, combining an evidence-based parenting intervention with depression treatment to improve both maternal and child outcomes. Our approach is part of a growing field of two-generation interventions that offer a promising approach to enhance mental health support for caregivers and their young children.

Investigation of the feasibility and acceptability of a school-based intervention for children with traits of ADHD: protocol for an iterative case-series study.

INTRODUCTION: Attention deficit/hyperactivity disorder (ADHD) is a prevalent and impairing cluster of traits affecting 2%-5% of children. These children are at risk of negative health, social and educational outcomes and often experience severe difficulties at school, so effective psychosocial interventions are needed. There is mixed evidence for existing school-based interventions for ADHD, which are complex and resource-intensive, contradicting teachers' preferences for short, flexible strategies that suit a range of ADHD-related classroom-based problems. They are also poorly evaluated. In this study, a prototype intervention comprising a digital 'toolkit' of behavioural strategies will be tested and refined. We aim to refine the prototype so that its use is feasible and acceptable within school settings, and to establish whether a future definitive, appropriately powered, trial of effectiveness is feasible. This novel iterative study aims to pre-emptively address implementation and evaluation challenges that have hampered previous randomised controlled trials of non-pharmacological interventions. METHODS AND ANALYSIS: A randomised iterative mixed-methods case-series design will be used. Schools will be randomised to the time (school term) they implement the toolkit. Eight primary schools and 16-32 children with impairing traits of ADHD will participate, along with school staff and parents. The toolkit will be refined after each term, or more frequently if needed. Small, theory-based and data driven changes hypothesised as relevant across school contexts will be made, as well as reactive changes addressing implementation barriers. Feasibility and acceptability will be assessed through quantitative and qualitative data collection and analyses in relation to study continuation criteria, and ADHD symptoms and classroom functioning will be tracked and visually evaluated to assess whether there are early indications of toolkit utility. ETHICS AND DISSEMINATION: Ethical approval has been obtained. Results will be presented in journal articles, conferences and through varied forms of media to reach policymakers, stakeholders and the public.

Development of a Web-Based Training Platform for School Clinicians in Evidence-Based Practices for ADHD.

Lack of training for school clinicians in evidence-based practices (EBPs) contributes to underutilization of such services for youth with attention-deficit/hyperactivity disorder (ADHD). Advances in web-based technology and videoconferencing have allowed for expanded access to and optimization of training. We describe the development and outcomes of a novel web-based platform for training school clinicians to gain skills in EBPs for school-age youth with ADHD. The training platform is adapted from an empirically supported, in-person training for a school-home behavioral intervention (Collaborative Life Skills program) and includes skill modules for working with teachers, parents, and students. Training methods include web-accessed manuals/handouts, skill example video clips, automated progress monitoring tools, and consultation/in-session coaching via videoconferencing. We gathered stakeholder qualitative and quantitative feedback during discovery and design phases of the iterative development. We then evaluated the usability, acceptability, fidelity and clinician and student outcomes of the remote training program. Focus group themes and qualitative feedback identified clinician preferences for remote training features (e.g., interactive, brief, role-plays/coaching methods), video tools (recorded samples of skills and therapy sessions), and progress monitoring tools (e.g., clear, easy to use). Clinician usability ratings of the platform were high with most components rated as moderately to very useful/easy to use. Clinician ratings of usability, fidelity implementing the treatment, and their EBP knowledge and confidence following training were favorable. Student's outcomes were similar to those achieved in prior studies of clinician in-person training. Results support the promise of remote, web-based clinician training for the dissemination of evidence-based practices.

Enhancing accessibility and scalability of school-based programs to improve youth attention and behavior: Open feasibility trial of the remote CLS-R-FUERTE program in Mexico.

Neurodevelopmental disorders of inattention and disruptive behavior, such as attention-deficit/hyperactivity disorder and oppositional defiant disorder, are among the most common youth mental health conditions across cultures. There is a need to develop more accessible school-based intervention and training programs, as well as create a system with clinical research capacity for scalable school clinician training and evaluation, to support students with attention and behavior concerns worldwide. We adapted the collaborative life skills program for Mexico (i.e., CLS-FUERTE) for remote delivery (i.e., CLS-R-FUERTE) and conducted a three-school open trial with N = 67 participants (n = 7-8 students per school [ages 6-12] and their parents, teachers, and school clinicians). We examined fidelity to program content, attendance and adherence records, in vivo observations of program delivery, and postmeeting feedback informing iterative program changes between each school cohort. We also examined improvements in youth attention and behavior rated by parents and teachers to evaluate the remote program effectiveness. CLS-R-FUERTE feasibility, acceptability, and usability findings were promising. Iterative program changes between each school cohort were minor and included adapted curriculum order, enhanced engagement strategies, and technology adjustments. Many students demonstrated reliable change, and the pre-post program improvements were comparable to outcomes from the in-person CLS-FUERTE trial, indicating preliminary effectiveness. Our pilot CLS-R-FUERTE effort supports the process of iteratively adapting, implementing, and evaluating remote school-based intervention and training programs to enhance potential flexibility, accessibility, and scalability. Challenges emerging from technological problems and in context of the COVID-19 pandemic, as well as solutions, are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Two-Factor Structure of the Parent Cognitive Error Questionnaire: A Measure of Parental Cognitive Errors in Relation to Child Problems.

This study evaluated the factor structure of the scores from a parent rating scale, the Parent Cognitive Error Questionnaire (PCEQ), which measures parents' attributions of child misbehavior and problems. The factor structure of the scores of the PCEQ was examined among 199 children (ages 7-11; mean age: 8.64 years, 58.30% boys, 53.80% White) with Attention-Deficit/Hyperactivity Disorder (ADHD), Predominantly Inattentive Presentation. Reliability and validity of the factors were assessed. Two factors emerged from this sample: (1) parent-specific cognitive errors (self-blame for child problems), and (2) child-specific cognitive errors (child-blame for child problems). Both were related to parent-rated parental depression, parenting satisfaction, parenting self-efficacy, and child ADHD and Oppositional Defiant Disorder (ODD) symptoms. After adjusting for child-specific cognitive errors, parent-specific errors were related to parent-rated parent depressive symptoms, and after adjustment for parent-specific cognitive errors, child-specific cognitive errors were related to parent-rated child ADHD and ODD symptoms. A two-factor structure for the PCEQ scores from this sample was found with evidence of reliability and validity of factors, showing promise for measuring sources of parental attributions regarding child problems.

Synthesising the existing evidence for non-pharmacological interventions targeting outcomes relevant to young people with ADHD in the school setting: systematic review protocol.

BACKGROUND: Children and adolescents with attention-deficit/hyperactivity disorder (ADHD) have impairing levels of difficulty paying attention, impulsive behaviour and/or hyperactivity. ADHD causes extensive difficulties for young people at school, and as a result these children are at high risk for a wide range of poor outcomes. We ultimately aim to develop a flexible, modular 'toolkit' of evidence-based strategies that can be delivered by primary school staff to improve the school environment and experience for children with ADHD; the purpose of this review is to identify and quantify the evidence-base for potential intervention components. This protocol sets out our plans to systematically identify non-pharmacological interventions that target outcomes that have been reported to be of importance to key stakeholders (ADHD symptoms, organisation skills, executive-global- and classroom-functioning, quality of life, self-esteem and conflict with teachers and peers). We plan to link promising individual intervention components to measured outcomes, and synthesise the evidence of effectiveness for each outcome. METHODS: A systematic search for studies published from the year 2000 that target the outcomes of interest in children and young people aged 3-12 will be conducted. Titles and abstracts will be screened using prioritisation software, and then full texts of potentially eligible studies will be screened. Systematic reviews, RCTs, non-randomised and case-series studies are eligible designs. Synthesis will vary by the type of evidence available, potentially including a review of reviews, meta-analysis and narrative synthesis. Heterogeneity of studies meta-analysed will be assessed, along with publication bias. Intervention mapping will be applied to understand potential behaviour change mechanisms for promising intervention components. DISCUSSION: This review will highlight interventions that appear to effectively ameliorate negative outcomes that are of importance for people with ADHD, parents, school staff and experts. Components of intervention design and features that are associated with effective change in the outcome will be delineated and used to inform the development of a 'toolkit' of non-pharmacological strategies that school staff can use to improve the primary school experience for children with ADHD. TRIAL REGISTRATION: PROSPERO number CRD42021233924.

Improving Adherence to Behavioral Parent Training for ADHD Using Digital Health Tools.

Behavioral Parent Training (BPT) is a well-established treatment for school-age children with ADHD but lack of parent adherence to prescribed parenting strategies limits treatment gains. Digital Health (dHealth) tools can be leveraged to target barriers to parent adherence but existing tools for parenting interventions are limited. New efforts to develop a dHealth tool to target adherence barriers including limited skill competence, EF processes, and low motivation/negative attitudes, are presented and recommendations for future technology-enhanced treatments are provided.