Moving forward. Use of the START NOW skills training program for female youth with ODD and CD - a commentary on Stadler et al. (2024).

Female youth with oppositional defiant disorder (ODD) and conduct disorder (CD) are an under studied and underserved population at high risk for poor adjustment in later life. Stadler et al. (2024) attempt to redress this situation for adolescent females with CD or ODD with an adapted version of the skills training program START NOW. They describe the results of an ambitious randomized control trial, comparing START NOW with standard care in youth welfare settings in Germany, Switzerland, and The Netherlands. The findings appear promising, but the paper is especially valuable for the spotlight it shines on the needs of this underserved population and those caring for them, together with the importance of undertaking such trials despite their challenges. This commentary seeks to encourage readers to engage with the START NOW trial.

A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of Well Parent Japan in routine care in Japan: The training and nurturing support for mothers (TRANSFORM) study.

BACKGROUND: Well Parent Japan (WPJ) is a new hybrid group parent training programme combining sessions to improve mothers' psychological well-being with a culturally adapted version of the New Forest Parenting Programme (NFPP). This study investigates the effectiveness and cost-effectiveness of WPJ against treatment as usual (TAU) within Japanese child mental health services. METHODS: TRANSFORM was a pragmatic multi-site randomised controlled trial (RCT) with two parallel arms. Altogether 124 mothers of 6-12-year-old children with DSM-5 ADHD were randomised to WPJ (n = 65) or TAU (n = 59). Participants were assessed at baseline, post-treatment and three-month follow-up. The primary outcome was parent-domain stress following intervention. Secondary outcomes included maternal reports of child-domain stress, parenting practices, parenting efficacy, mood, family strain, child behaviour and impairment. Objective measures of the parent-child relationship were collected at baseline and post-treatment. Data analysis was intention to treat (ITT) with treatment effects quantified through analysis of covariance (ANCOVA) via multilevel modelling. An incremental cost-effectiveness ratio (ICER) assessed WPJ's cost-effectiveness. RESULTS: WPJ was superior to TAU in reducing parent-domain stress post-treatment (adjusted mean difference = 5.05, 95% CI 0.33 to 9.81, p = .036) and at follow-up (adjusted mean difference 4.82, 95% CI 0.09 to 9.55, p = .046). Significant WPJ intervention effects were also observed for parenting practices, parenting efficacy and family strain. WPJ and TAU were not significantly different post-intervention or at follow-up for the other secondary outcomes. The incremental cost of WPJ was 34,202 JPY (315.81 USD). The probability that WPJ is cost-effective is 74% at 10,000 JPY (USD 108.30) per one-point improvement in parenting stress, 92% at 20,000 JPY (216.60 USD). The programme was delivered with high fidelity and excellent retention. CONCLUSIONS: WPJ can be delivered in routine clinical care at modest cost with positive effects on self-reported well-being of the mothers, parenting practices and family coping. WPJ is a promising addition to psychosocial interventions for ADHD in Japan.

Instrumental learning and behavioral persistence in children with attention-deficit/hyperactivity-disorder: does reinforcement frequency matter?

BACKGROUND: Prominent theoretical accounts of attention-deficit/hyperactivity-disorder (ADHD) hypothesize that reinforcement learning deficits underlie symptoms of ADHD. The Dynamic Developmental Theory and the Dopamine Transfer Deficit hypothesis assume impairments in both the acquisition and extinction of behavior, especially when learning occurs under partial (non-continuous) reinforcement, and subsequently the Partial Reinforcement Extinction Effect (PREE). Few studies have evaluated instrumental learning in ADHD and the results are inconsistent. The current study investigates instrumental learning under partial and continuous reinforcement schedules and subsequent behavioral persistence when reinforcement is withheld (extinction) in children with and without ADHD. METHODS: Large well-defined samples of children with ADHD (n = 93) and typically developing (TD) children (n = 73) completed a simple instrumental learning task. The children completed acquisition under continuous (100%) or partial (20%) reinforcement, followed by a 4-min extinction phase. Two-way (diagnosis by condition) ANOVAs evaluated responses needed to reach the learning criterion during acquisition, and target and total responses during extinction. RESULTS: Children with ADHD required more trials to reach criterion compared to TD children under both continuous and partial reinforcement. After partial reinforcement, children with ADHD executed fewer target responses during extinction than TD children. Children with ADHD executed more responses than TD children during extinction, irrespective of learning condition. CONCLUSIONS: The findings demonstrate general difficulties in instrumental learning in ADHD, that is, slower learning irrespective of reinforcement schedule. They also show faster extinction following learning under partial reinforcement in those with ADHD, that is, a diminished PREE. Children with ADHD executed more responses during extinction. Results are theoretically important, with clinical implications for understanding and managing learning difficulties in those with ADHD, as they suggest poorer reinforcement learning and lower behavioral persistence.

The profile of pragmatic language impairments in children with ADHD: A systematic review.

This systematic review synthesizes the empirical literature examining pragmatic language in children diagnosed with attention-deficit/hyperactivity disorder (ADHD). Using a taxonomy of pragmatic language, we compared the pragmatic language profiles of children with ADHD to those of typically developing (TD) children and children with autism. Three databases were searched up to October 2019: PsychInfo; PubMed; and CSA Linguistics and Language Behavior Abstracts. We included 34 studies reporting on 2,845 children (ADHD = 1,407; TD = 1,058; autism = 380). Quality and risk of bias assessments included sample size and representativeness; measure reliability and validity; and missing data management. Children with ADHD were found to have higher rates of pragmatic difficulties than their TD peers. Specific difficulties were identified with inappropriate initiation, presupposition, social discourse, and narrative coherence. Children with ADHD appear to differ from those with autism in the degree of their pragmatic language impairments. General language skills contribute to, but do not explain, pragmatic difficulties in samples of children with ADHD. Though the extant evidence is limited, a preliminary profile of the pragmatic language impairments in children with ADHD is indicated. This supports a call for evidence-based interventions that include pragmatic language skills training.

Behavioral sensitivity of Japanese children with and without ADHD to changing reinforcer availability: an experimental study using signal detection methodology.

BACKGROUND: Most research on motivational processes in attention deficit hyperactivity disorder (ADHD) has been undertaken in Western Europe and North America. The extent to which these findings apply to other cultural groups is unclear. The current study evaluated the behavioral sensitivity of Japanese children with and without ADHD to changing reward availability. Forty-one school-aged children, 19 diagnosed with DSM-IV ADHD, completed a signal-detection task in which correct discriminations between two stimuli were associated with different reinforcement frequencies. The response alternative associated with the higher rate of reinforcement switched twice during the task without warning. FINDINGS: Both groups of children developed an initial bias toward the more frequently reinforced response alternative. When the reward contingencies switched the response allocation (bias) of the control group children followed suit. The response bias scores of the children with ADHD did not, suggesting impaired tracking of reward availability over time. CONCLUSIONS: Japanese children with ADHD adjust their behavioral responses to changing reinforcer availability less than their typically developing peers. This is not explained by poor attention to task or a lack of sensitivity to reward. The current results are consistent with altered sensitivity to changing reward contingencies identified in non-Japanese samples of children with ADHD. Irrespective of their country of origin, children with ADHD will likely benefit from behavioral expectations and reinforcement contingencies being made explicit together with high rates of reinforcement for appropriate behaviors.

Evidence for increased behavioral control by punishment in children with attention-deficit hyperactivity disorder.

BACKGROUND: The behavioral sensitivity of children with ADHD to punishment has received limited theoretical and experimental attention. This study evaluated the effects of punishment on the response allocation of children with ADHD and typically developing children. METHOD: Two hundred and ten children, 145 diagnosed with ADHD, completed an operant task in which they chose between playing two simultaneously available games. Reward was arranged symmetrically across the games under concurrent variable interval schedules. Asymmetric punishment schedules were superimposed; responses on one game were punished four times as often as responses on the other. RESULTS: Both groups allocated more of their responses to the less frequently punished alternative. Response bias increased significantly in the ADHD group during later trials, resulting in missed reward trials and reduced earnings. CONCLUSIONS: Punishment exerted greater control over the response allocation of children with ADHD with increased time on task. Children with ADHD appear more sensitive to the cumulative effects of punishment than typically developing children.

Behavioral sensitivity to changing reinforcement contingencies in attention-deficit hyperactivity disorder.

BACKGROUND: Altered sensitivity to positive reinforcement has been hypothesized to contribute to the symptoms of attention-deficit hyperactivity disorder (ADHD). In this study, we evaluated the ability of children with and without ADHD to adapt their behavior to changing reinforcer availability. METHOD: Of one hundred sixty-seven children, 97 diagnosed with ADHD completed a signal-detection task in which correct discriminations between two stimuli were associated with different frequencies of reinforcement. The response alternative associated with the higher rate of reinforcement switched twice during the task without warning. For a subset of participants, this was followed by trials for which no reinforcement was delivered, irrespective of performance. RESULTS: Children in both groups developed an initial bias toward the more frequently reinforced response alternative. When the response alternative associated with the higher rate of reinforcement switched, the children's response allocation (bias) followed suit, but this effect was significantly smaller for children with ADHD. When reinforcement was discontinued, only children in the control group modified their response pattern. CONCLUSIONS: Children with ADHD adjust their behavioral responses to changing reinforcer availability less than typically developing children, when reinforcement is intermittent and the association between an action and its consequences is uncertain. This may explain the difficulty children with ADHD have adapting their behavior to new situations, with different reinforcement contingencies, in daily life.

Using rodent data to elucidate dopaminergic mechanisms of ADHD: Implications for human personality.

An altered behavioral response to positive reinforcement has been proposed to be a core deficit in attention deficit hyperactivity disorder (ADHD). The spontaneously hypertensive rat (SHR), a congenic animal strain, displays a similarly altered response to reinforcement. The presence of this genetically determined phenotype in a rodent model allows experimental investigation of underlying neural mechanisms. Behaviorally, the SHR displays increased preference for immediate reinforcement, increased sensitivity to individual instances of reinforcement relative to integrated reinforcement history, and a steeper delay of reinforcement gradient compared to other rat strains. The SHR also shows less development of incentive to approach sensory stimuli, or cues, that predict reward after repeated cue-reward pairing. We consider the underlying neural mechanisms for these characteristics. It is well known that midbrain dopamine neurons are initially activated by unexpected reward and gradually transfer their responses to reward-predicting cues. This finding has inspired the dopamine transfer deficit (DTD) hypothesis, which predicts certain behavioral effects that would arise from a deficient transfer of dopamine responses from actual rewards to reward-predicting cues. We argue that the DTD predicts the altered responses to reinforcement seen in the SHR and individuals with ADHD. These altered responses to reinforcement in turn predict core symptoms of ADHD. We also suggest that variations in the degree of dopamine transfer may underlie variations in personality dimensions related to altered reinforcement sensitivity. In doing so, we highlight the value of rodent models to the study of human personality.

Relationships between experimental task and questionnaire measures of reward/punishment sensitivity in attention-deficit/hyperactivity disorder (ADHD): protocol for a scoping review.

INTRODUCTION: One of the purported underlying causal mechanisms of attention deficit hyperactivity disorder (ADHD) is altered motivational processes. Questionnaires have been used to identify the characteristics of reward and punishment sensitivity in individuals with ADHD. However, these questionnaires were initially developed to measure individual traits related to anxiety (inhibitory) and impulsivity (approach) tendencies or differences in pleasure-seeking. These reward and punishment sensitivity questionnaires are useful but might not capture all relevant aspects of altered motivational processes in ADHD. The proposed scoping review aims to: (1) examine which aspects of hypothesised altered reward and punishment sensitivity correspond to constructs measured by existing questionnaires, (2) characterise the relationships between ADHD symptomatology and reward and punishment sensitivity as measured by existing questionnaires and (3) evaluate the consistency between the altered reward and punishment sensitivity as measured by existing questionnaires and experimental task performance. METHODS AND ANALYSIS: Reporting of the scoping review results will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews and the Joanna Briggs Methodology for Scoping Reviews. Published English-language literature was searched in three electronic databases (PubMed, Web of Science, APA PsycINFO) on 16 November 2023, with no restriction on the year of publication. Two researchers independently screened all identified titles/abstracts before proceeding to full-text review and additional handsearching of relevant studies. A narrative review and conclusions will be presented together with tables summarising the articles reviewed and the results organised by the three aims. ETHICS AND DISSEMINATION: This study reviews existing publications with ethical approval in place. Therefore, ethical approval is not required. Review results will be disseminated through academic conferences and peer-reviewed manuscripts. Scoping review results will also inform future research to measure and identify altered motivational processes in ADHD.

Behavioral and Emotional Responding to Punishment in ADHD: Is Increased Emotionality Related to Altered Behavioral Responding?

Children with ADHD are theorized to experience increased negative emotional responses to punishment, compared to typically developing (TD) children, resulting in altered behavioral responding (Amsel, 1992). However, this has not been empirically tested. The current study evaluated the effects of punishment and reward on the behavioral and emotional responding of children with and without ADHD. Fifty-three children with ADHD (64.15% boys) and 46 TD children (47.83% boys), age 6-12, completed a task in which they chose between playing two simultaneously available games. Reward was arranged symmetrically across the games; responses on one game were punished four times as often as responses on the other game. Children's negative and positive emotional expressions were assessed during task completion with facial expression coding. Results indicated both groups showed a preference for playing the less punished game. Children with ADHD took longer to respond after punishment and reward compared to TD children. Negative emotional expressions increased with time on task for those with ADHD, the opposite pattern was seen in TD children. Children with ADHD showed more positive emotional expressions overall. The effect of ADHD on increased response times after reward was statistically fully mediated by increased positive facial expressions. Findings indicate children with ADHD do not show an altered response bias under punishment compared to TD children, but their cumulative negative emotional responding may indicate problems with building frustration tolerance as hypothesized by Amsel (1992). Results are theoretically important as they suggest increased emotional responding in ADHD is associated with slower responding.

Is waiting for rewards good for you? No association between impulsive choice, psychopathology, and functional outcomes in a large cohort sample.

Background: A stronger preference for immediate rewards has been reported in individuals with ADHD and other disorders. However, the consistency of the associations between this preference and psychiatric conditions as well as functional outcomes have been questioned. Research on its association with longitudinal outcomes is scarce. Methods: The current study used data on a choice delay task (CDT) from a school-based cohort of Brazilian children with those at higher risk for psychiatric disorders over-sampled (n = 1917). The sample included typically developing children (n = 1379), those with ADHD (n = 213), and other disorders. The frequency of the trials where children chose a larger later reward versus a smaller sooner reward was compared for those with ADHD and typically developing children. Cross-sectionally and longitudinally, the study also evaluated whether children's preference for larger delayed rewards at baseline predicted the presence of psychiatric disorders and functional life outcomes (academic performance, alcohol use, early pregnancy, criminal conviction, BMI). Results: Children with ADHD and their typically developing peers performed similarly on the CDT. Their baseline task performance was not related to psychiatric conditions or life outcomes. Conclusions: The current results raise questions regarding the use of the CDT with diverse populations and whether a preference for larger delayed rewards is predictive of positive long-term outcomes as widely assumed.

Altered functional brain connectivity in a non-clinical sample of young adults with attention-deficit/hyperactivity disorder.

Attention-deficit/hyperactivity disorder (ADHD) is characterized by symptoms of inattention and hyperactivity/impulsivity that often persist in adulthood. There is a growing consensus that ADHD is associated with abnormal function of diffuse brain networks, but such alterations remain poorly characterized. Using resting-state functional magnetic resonance imaging, we characterized multivariate (complex network measures), bivariate (network-based statistic), and univariate (regional homogeneity) properties of brain networks in a non-clinical, drug-naive sample of high-functioning young men and women with ADHD (nine males, seven females) and a group of matched healthy controls. Data from our sample allowed the isolation of intrinsic functional connectivity alterations specific to ADHD diagnosis and symptoms that are not related to developmental delays, general cognitive dysfunction, or history of medication use. Multivariate results suggested that frontal, temporal, and occipital cortices were abnormally connected locally as well as with the rest of the brain in individuals with ADHD. Results from the network-based statistic support and extend multivariate results by isolating two brain networks comprising regions between which inter-regional connectivity was significantly altered in the ADHD group; namely, a frontal amygdala-occipital network and a frontal temporal-occipital network. Brain behavior correlations further highlighted the key role of altered orbitofrontal-temporal and frontal-amygdala connectivity for symptoms of inattention and hyperactivity/impulsivity. All univariate properties were similar between groups. Taken together, results from this study show that the diagnosis and the two main symptom dimensions of ADHD are related to altered intrinsic connectivity in orbitofrontal-temporal-occipital and fronto-amygdala-occipital networks. Accordingly, our findings highlight the importance of extending the conceptualization of ADHD beyond segregated fronto-striatal alterations.

Conditioned approach behavior of SHR and SD rats during Pavlovian conditioning.

Individual differences in reward-related learning are relevant to many behavioral disorders. Sensory cues that predict reward can become incentive stimuli that adaptively support behavior, or alternatively, cause maladaptive behaviors. The spontaneously hypertensive rat (SHR) expresses a genetically determined elevated sensitivity to delay of reward, and has been extensively studied as a behavioral model for attention deficit hyperactivity disorder (ADHD). We investigated reward-related learning in the SHR, comparing them to Sprague-Dawley (SD) rats as a reference strain. A standard Pavlovian conditioned approach task was used, in which a lever cue was followed by reward. Lever presses could occur while the lever was extended, but had no effect on reward delivery. The behavior of both the SHRs and the SD rats showed that they learnt that the lever cue predicted reward. However, the pattern of behavior differed between the strains. During lever cue presentation, SD rats pressed the lever more often and made fewer magazine entries than SHRs. When lever contacts that did not result in lever presses were analyzed, there was no significant difference between SHRs and SDs. These results suggest that the SHRs attributed less incentive value to the conditioned stimulus than the SD rats. During the presentation of the conditioned cue, cue directed responses are called sign tracking responses, whereas responses directed towards the food magazine are called goal tracking responses. Analysis of behavior using a standard Pavlovian conditioned approach index to quantify sign and goal tracking tendencies showed that both strains had a tendency towards goal tracking in this task. However, the SHRs showed a significantly greater goal tracking tendency than the SD rats. Taken together, these findings suggest that attribution of incentive value to reward predicting cues is attenuated in SHRs, which might explain their elevated sensitivity to delay of reward.

Needs assessment for behavioral parent training for ADHD in Brazil.

Introduction: Attention-Deficit/Hyperactivity Disorder (ADHD) is a debilitating condition affecting children and their families worldwide. Behavioral parent training is a recommended form of empirically supported non-pharmacological intervention for young children with mild to moderate ADHD. However, access to such treatment is limited in many countries. Here we identify the treatment needs of Brazilian families with children demonstrating symptoms of ADHD, and the barriers families face in accessing behavioral treatment. Methods: A qualitative needs assessment was undertaken with parents (n = 23), educators (n = 15), and healthcare providers (n = 16). Semi-structured telephone interviews were conducted, and common themes were identified through inductive coding of participants' responses. Results: Participants reported a lack of accessible behavioral treatment, and delays in accessing treatment when available. The majority of parents had not received behavioral parent training, despite it being a recommended form of treatment. Parents, educators and healthcare providers strongly endorsed a need for practical tools to manage the behavior of children with ADHD. Conclusion: Existing services might not meet the needs of children with ADHD and their families in Brazil. Easily accessed behavioral parent training programs are recommended to address the identified treatment gap for Brazilian children with ADHD and their families.

Disrupted waiting behavior in ADHD: exploring the impact of reward availability and predictive cues.

Altered motivational processing is purported to contribute to ADHD symptoms. A stronger preference for immediate over delayed reward is well documented in ADHD. However, little attention has been paid to children's capacity to withhold responding until a "better" reward becomes available, and their actions while waiting. Using a novel computer task, we examine the ability of children with and without ADHD to wait to collect a large reward in the presence of a small available reward. The effects of a reward-predicting cue on response times and response choices are also explored. Data from 136 children (6-12 years), 90 with ADHD and 46 typically developing (TD) children, are included. The children could collect a small immediately available reward or wait to access a larger reward after a variable delay, its imminent availability sometimes signaled by a cue. Subsequent probe trials explored the effects of longer waiting times and disruption of the cue-reward association. As expected, children with ADHD collected the small immediately available reward more often than TD children. Importantly, they were more likely to terminate waiting once commenced, collecting the small reward or attempting to collect the large reward early. The cue decreased their response time but disrupted their waiting when it no longer consistently predicted reward. Children with ADHD were more likely to abandon efforts to wait, especially when wait times were extended and when expected rewards failed to appear. Behavioral interventions for ADHD should take into account reduced waiting capacity that extends beyond children's preference for immediate reward.

Shared Predictors of Academic Achievement in Children with ADHD: A Multi-Sample Study.

OBJECTIVE: To identify common and shared predictors of academic achievement across samples of children with ADHD. METHOD: Two clinically referred samples from New Zealand (1 n = 88, 82% boys; 2 n = 121, 79% boys) and two community samples from the United States (3 n = 111, 65% boys; 4 n = 114, 69% boys), completed similar diagnostic, cognitive and academic assessments. Hierarchical multiple regression analyses identified significant predictors of word reading, spelling, and math computation performance in each sample. RESULTS: Entered after IQ, semantic language, age at testing, and verbal working memory emerged as consistent predictors of achievement across academic subjects and samples. Visual-spatial working memory contributed to variance in math performance only. Symptom severity explained limited variance. CONCLUSIONS: We recommend evaluations of children with ADHD incorporate assessments of working memory and language skills. Classroom/academic interventions should accommodate reduced working memory and address any identified language weaknesses.

Wishes of Children With ADHD.

Understanding the desires and motivations of children with ADHD is important in helping them thrive. Their inner worlds, however, have not been well captured. The Three Wishes task provides minimal cues and structure to elicit their desires and hopes in an unbiased manner. The wishes of 299 school-aged children with ADHD (193 boys, aged 6-12) were elicited during a research diagnostic assessment. We developed a coding scheme to characterize different aspects of their wishes, including beneficiary, valence, and immediacy. Maslow's hierarchy of needs, adapted to take account of the participants' ages, was used to identify the motivations underlying the children's wishes. As expected, many of the wishes reported were for immediate fulfillment, with many reflecting material desires. Affiliative wishes, highlighting the children's desire for positive interpersonal relationships, were also common. There was some evidence for self-actualization/self-betterment goals and a small number of altruistic wishes. A word cloud presents the content of the children's wishes grouped according to this hierarchy. This study highlights the diversity and typicality of the self-reported needs, desires and hopes of children with ADHD. It also serves as a timely reminder of the value of seeking such information directly from children themselves.

Interpersonal negotiation skills in ADHD.

Social interaction difficulties are amongst the most prevalent and pervasive adverse outcomes for children and adolescents with ADHD. Problem-solving strategies are impaired in affected individuals, according to the literature. This study aimed to investigate the social problem-solving skills of children and adolescents with and without ADHD, using objective quantitative measures provided by the Interpersonal Negotiation Strategies Interview (INSI). Since verbal communication skills and working memory may be impaired in ADHD, we investigated their contribution to the performance. Forty-three children and adolescents with ADHD and 27 clinical controls with clinical diagnoses other than ADHD completed the INSI along with measures of verbal communication skills (Verbal Comprehension Index [VCI]): Similarities, Vocabulary and Comprehension subtests from the Wechsler Battery, visual (Corsi Blocks) and verbal (Digit Span) working memory tasks. Groups performed similarly on measures of intellectual functioning, working memory, and verbal communication. For the entire sample, VCI scores were positively correlated with INSI performance scores. The ADHD group performed worse on the INSI than the clinical control group. Linear regression analysis showed that inattention and hyperactivity/impulsivity levels and Similarities predicted INSI's performance. Our findings indicate that interpersonal negotiation difficulties in ADHD are related to DSM-5 defining symptoms of the disorder.

Use of the Brazilian version of the Interpersonal Negotiation Strategies Interview (INSI) in a child and adolescent sample: a pilot study.

INTRODUCTION: Interpersonal negotiation skills (INS) comprise actions used to solve social situations between interacting individuals involving different needs or desires. These abilities are part of one's social competence and may be impaired in some psychiatric conditions. There are few validated psychometric tools for measuring INS in the literature. This pilot study aimed to investigate some basic psychometric properties of the Brazilian version of the Interpersonal Negotiation Strategies Interview (INSI) in children and adolescents. METHODS: We developed a new version of the INSI adapted to the Brazilian culture using eight different dilemmas in dyadic situations (with peers and adults), presented visually as drawings on cards. A group of psychologists and psychiatrists chose and adapted the dilemmas formerly proposed by the original version. The same scoring criteria as for the original instrument were used. A total of 20 children and adolescents were included in this pilot study. We investigated test reliability using measures of interrater reliability, test-retest, and internal consistency. The content validity of the INSI was also evaluated by comparison with scores from the Child Behavior Checklist-Revised (CBCL). RESULTS: Internal consistency and test-retest evaluations were acceptable (rater 1: α = 0.77; rater 2: α = 0.72); the reliability of the instrument was excellent (K = 0.078; intraclass correlation coefficient = 0.98; 95% confidence interval 0.97-0.99); and content validity was strongly significant (p < 0.001). CONCLUSIONS: Preliminary results suggest that this version of the INSI has good interrater reliability and internal consistency and constitutes a promising tool to assess social competence.

The Effectiveness and Cost-effectiveness of Well Parent Japan for Japanese Mothers of Children With ADHD: Protocol for a Randomized Controlled Trial.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder associated with numerous functional deficits and poor long-term outcomes. Internationally, behavioral interventions are recommended as part of a multimodal treatment approach for children with ADHD. Currently, in Japan, there are limited interventions available to target ADHD. Well Parent Japan (WPJ), a new hybrid parent-training program, provides a culturally acceptable and effective way to help support Japanese children with ADHD and their parents. OBJECTIVE: This pragmatic multicenter randomized controlled trial aims to provide preliminary evidence about the effectiveness and cost-effectiveness of WPJ evaluated against treatment as usual (TAU) within routine Japanese mental health services. METHODS: Mothers of children (aged 6-12 years) diagnosed with ADHD were recruited from child and adolescent mental health care services at three hospital sites across Japan (Fukui, Fukuoka, and Okinawa). The mothers were randomized to receive immediate treatment or TAU. The effectiveness and cost-effectiveness of WPJ over TAU at the end of the intervention and at 3-month follow-up will be evaluated. The primary outcome is maternal parent domain stress in the parenting role. The following secondary outcomes will be explored: child behavior, including severity of ADHD symptoms; parenting practices; emotional well-being; and the parent-child relationship and maternal child domain parenting stress. Data analysis will follow intention-to-treat principles with treatment effects quantified through analysis of covariance using multilevel modeling. An incremental cost-effectiveness ratio will be used to analyze the cost-effectiveness of the WPJ intervention. RESULTS: Study funding was secured through a proof-of-concept grant in July 2018. Approval by the institutional review board for the data collection sites was obtained between 2017 and 2019. Data collection began in August 2019 and was completed in April 2022. Participant recruitment (N=124) was completed in May 2021. Effectiveness and cost-effectiveness analyses are expected to be completed by July 2022 and December 2022, respectively. These timelines are subject to change owing to the COVID-19 pandemic. CONCLUSIONS: This is the first multisite pragmatic trial of WPJ based on the recruitment of children referred directly to routine clinical services in Japan. This multisite randomized trial tests the effectiveness of WPJ in children and families by comparing WPJ directly with the usual clinical care offered for children diagnosed with ADHD in Japan. We also seek to assess and compare the cost-effectiveness of WPJ with TAU in Japan. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number ISRCTN66978270; https://www.isrctn.com/ISRCTN66978270. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/32693.