The problem of vaccination refusal: a review with guidance for pediatricians.

PURPOSE OF REVIEW: In the wake of multiple recent outbreaks of the measles and other vaccine-preventable diseases, it is crucial to understand and address parental concerns about vaccination. The purposes of this review are: to identify the causes of vaccine resistance, to elucidate the variables that have led to the success or failure of interventions to date, and to consider implications for pediatricians treating children whose parents are vaccination-resistant. RECENT FINDINGS: Recent research draws on insights from cognitive science to understand vaccine resistance and to develop more effective interventions. Studies show that vaccine resistors are more likely to value lifestyle liberty, to favor individualistic over hierarchical worldviews, and to believe in conspiracy theories. Interventions that seek primarily to correct erroneous beliefs about the dangers of vaccination are likely to fail or even backfire. On the other hand, intervention strategies, such as motivational interviewing, in which the provider elicits and shows respect for parents' values and concerns while empowering them to make well informed and well reasoned decisions, are more likely to be successful. Parents cite a trusting relationship with their pediatrician as the most important factor influencing their decision to vaccinate. SUMMARY: Pediatricians are in the best position to successfully apply insights from cognitive science and intervention research to overcome vaccination-hesitancy.

Commentary: Development of a new, much-needed, cognitive-behavioral intervention for adolescents with ADHD - a reflection on Sprich et al. (2016).

Adolescents with attention deficit hyperactivity disorder (ADHD) can be challenging to treat. often, they are resistant to taking medication. Furthermore, the behavioral and cognitive-behavioral interventions developed for children and adults with ADHD, are not appropriate or are not effective for adolescents. Thus, this study, showing the effectiveness of a cognitive-behavioral treatment (CBT) program specifically designed for adolescents, represents an important step forward. Methodological strengths include a wait-list control group and outcome ratings by a blind evaluator. We look forward to further development of this treatment, particularly a trial in adolescents not concomitantly medicated for ADHD and comparison to an active control group.

The Adverse Health Outcomes, Economic Burden, and Public Health Implications of Unmanaged Attention Deficit Hyperactivity Disorder (ADHD): A Call to Action Resulting from CHADD Summit, Washington, DC, October 17, 2019.

Recent research has increasingly documented the adverse effects of ADHD on physical health in addition to its well-known effects on emotional health. Responding to this concern, CHADD organized a summit meeting of health care providers, governmental and other health-related organizations, and health care payers. A White Paper generated from the meeting reviewed the adverse health outcomes, economic burden and public health implications of unmanaged ADHD. Here we summarize the resulting Calls to Action to the various stakeholder groups including: increased awareness and education of providers; development of professional guidelines for diagnosis and treatment; insurance coverage of the relevant services; support of research targeting the role of ADHD in the etiology and treatment of physical illness; and public education campaigns.

Do ADHD Symptoms, Executive Function, and Study Strategies Predict Temporal Reward Discounting in College Students with Varying Levels of ADHD Symptoms? A Pilot Study.

The purpose of this study was to examine the relationship between temporal reward discounting and attention deficit hyperactivity disorder (ADHD) symptoms in college students. Additionally, we examined whether temporal reward discounting was associated with executive functioning in daily life and with learning and study strategies in this group. Thirty-nine college students (19 with ADHD and 20 controls) participated after meeting criteria for ADHD or non-ADHD based on standardized assessment. Strong preferences for small immediate rewards were specifically associated with the ADHD symptom domain hyperactivity-impulsivity. Additionally, these preferences were associated with daily life executive function problems and with weak learning and study strategies. This suggests that steep temporal discounting may be a key mechanism playing a role in the daily life challenges that college students with ADHD symptoms face. If these findings are replicated in larger samples, then intervention strategies may profitably be developed to counteract this strong preference for small immediate rewards in college students with ADHD symptoms.

Feasibility, Acceptability, and Effectiveness of a New Cognitive-Behavioral Intervention for College Students with ADHD.

OBJECTIVE: This purpose of this study was to assess the feasibility, acceptability, and effectiveness of a new group cognitive-behavioral treatment (CBT) to enhance executive function (EF) in college students with ADHD. METHODS: Eighteen students meeting rigorous DSM-5 criteria for ADHD were enrolled in two nine-member groups. The treatment targeted time-awareness, distractibility, procrastination, and failure to plan, and included strategies to facilitate academic EF skills. RESULTS: Eighty-four percent of students attended nine or more of the 12 weekly sessions. Repeated measures analyses of change from pre- to posttreatment yielded improvement in clinician- and self-ratings of DSM-5 ADHD inattentive symptoms, with robust effect sizes. Also improved were scores on standardized scales of time-management, concentration, and total EF. DISCUSSION: Results provide support for the feasibility, acceptability, and effectiveness of a CBT program in reducing inattentive symptoms and enhancing EF in college students with ADHD, and warrant investigation on a larger scale.

Reliability of DSM-IV Symptom Ratings of ADHD: implications for DSM-V.

OBJECTIVE: The objective of this study was to examine the intrarater reliability of DSM-IV ADHD symptoms. METHOD: Two-hundred-two children referred for attention problems and 49 comparison children (all 7-12 years) were rated by parents and teachers on the identical DSM-IV items presented in two different formats, the SNAP-IV and Conners' Revised Questionnaires, at two closely spaced points in time. RESULTS: For the combined sample, weighted kappa scores for intrarater agreement ranged from .30 ("fair") to .77 ("good") across symptoms. Kappa scores were good with respect to agreement on the DSM-IV criterion of endorsement of at least six symptoms in a given cluster for Inattention (.60 and .76, for parents and teachers, respectively) and Hyperactivity-Impulsivity (.72 and .75, respectively). Kappas for identification of cases as AD/HD or not AD/HD were good to excellent (.67 and .79 for parents and teachers, respectively). Classification as AD/HD or not AD/HD changed from the first to the second rating in 12% and 10% of cases rated parents and teachers, respectively. CONCLUSION: Reliability of individual ADHD symptoms appears to be suboptimal for clinical and research use and is improved, although less than ideal, at the levels of cluster endorsement and case classification.

Social functioning in predominantly inattentive and combined subtypes of children with ADHD.

OBJECTIVE: The objective of this study was to compare the social functioning of children with the Combined (CB) and Predominantly Inattentive (PI) subtypes of Attention Deficit/Hyperactivity Disorder (ADHD), controlling for comorbidity and medication-status, which may have confounded the results of previous research. METHOD: Parents and teachers of rigorously diagnosed unmedicated children with PI or CB subtypes of ADHD, and typical comparison children, rated them on the multidimensional Social Skills Rating Scale (SSRS). RESULTS: After co-varying for oppositionality and anxiety, social impairment was substantial and equivalent in both ADHD groups whether rated by parent or teacher. In addition, when rated by teacher, the nature of the deficits varied by subtype: Children with PI were impaired in assertiveness, whereas children with CB were deficient in self-control. These findings indicate that AD/HD subtypes differ in the nature of their social dysfunction independent of comorbidity and highlight the need for interventions to target their divergent needs.

The Prevalence of "Late-Onset" ADHD in a Clinically Referred Adult Sample.

OBJECTIVE: Three recent prospective longitudinal studies of population cohorts reported nontrivial rates of "adult-onset" ADHD. Given that this result is at odds with the neurodevelopmental conceptualization of ADHD, as well as with general clinical experience, we obtained report of onset of symptoms in a clinical sample of adults diagnosed with ADHD. METHOD: One hundred four adults diagnosed with ADHD completed retrospective ratings of DSM-IV/DSM-5 ADHD symptoms between the ages of 5 and 12 years. RESULTS: Fifty percent of the sample met full retrospective child diagnostic symptom criteria of six ADHD symptoms in either the inattentive or hyperactive-impulsive domains. Seventy-five percent met a less stringent criterion of four symptoms in either domain. DISCUSSION: These results are interpreted in light of a dimensional model of ADHD that posits emergence of ADHD symptoms and corresponding impairment as a function of increasing performance demands and/or decreasing environmental supports during the course of development.

Depressed dopamine activity in caudate and preliminary evidence of limbic involvement in adults with attention-deficit/hyperactivity disorder.

CONTEXT: Attention-deficit/hyperactivity disorder (ADHD) is the most prevalent psychiatric disorder of childhood. There is considerable evidence that brain dopamine is involved in ADHD, but it is unclear whether dopamine activity is enhanced or depressed. OBJECTIVE: To test the hypotheses that striatal dopamine activity is depressed in ADHD and that this contributes to symptoms of inattention. DESIGN: Clinical (ADHD adult) and comparison (healthy control) subjects were scanned with positron emission tomography and raclopride labeled with carbon 11 (D2/D3 receptor radioligand sensitive to competition with endogenous dopamine) after placebo and after intravenous methylphenidate hydrochloride (stimulant that increases extracellular dopamine by blocking dopamine transporters). The difference in [11C]raclopride's specific binding between placebo and methylphenidate was used as marker of dopamine release. Symptoms were quantified using the Conners Adult ADHD Rating Scales. SETTING: Outpatient setting. PARTICIPANTS: Nineteen adults with ADHD who had never received medication and 24 healthy controls. RESULTS: With the placebo, D2/D3 receptor availability in left caudate was lower (P < .05) in subjects with ADHD than in controls. Methylphenidate induced smaller decrements in [11C]raclopride binding in left and right caudate (blunted DA increases) (P < .05) and higher scores on self-reports of "drug liking" in ADHD than in control subjects. The blunted response to methylphenidate in caudate was associated with symptoms of inattention (P < .05) and with higher self-reports of drug liking (P < .01). Exploratory analysis using statistical parametric mapping revealed that methylphenidate also decreased [11C]raclopride binding in hippocampus and amygdala and that these decrements were smaller in subjects with ADHD (P < .001). CONCLUSIONS: This study reveals depressed dopamine activity in caudate and preliminary evidence in limbic regions in adults with ADHD that was associated with inattention and with enhanced reinforcing responses to intravenous methylphenidate. This suggests that dopamine dysfunction is involved with symptoms of inattention but may also contribute to substance abuse comorbidity in ADHD.

Research forum on psychological treatment of adults with ADHD.

BACKGROUND: A literature search found five empirical studies of psychological treatment for adults with ADHD, out of 1,419 articles on ADHD in adults. Practice guidelines to date all recommend multimodal intervention, given that a significant number of patients cannot tolerate, do not respond to, or fail to reach optimal outcomes with medication alone. METHOD: This article provides a literature review and the recommendations of a forum of experts in the psychological treatment of adults with ADHD. RESULTS: Empirical studies of brief, structured, and short-term psychological interventions for adults with ADHD to date demonstrate moderate to large effect sizes. Methodological challenges include selection of control groups, broad-based measures of outcome, and the need for larger samples. CONCLUSION: Psychological treatment may play a critical role in the management of adults with ADHD who are motivated and developmentally ready to acquire new skills as symptoms remit.

Development of a new psychosocial treatment for adult ADHD.

OBJECTIVE: The purpose of this study was to assess the effectiveness of a new manualized group Meta-Cognitive Therapy (MCT) for adults with ADHD that extends the principles and practices of cognitive-behavioral therapy to the development of executive self-management skills. METHOD: Thirty adults diagnosed with ADHD completed an 8- or 12-week program designed to target impairments in time management, organization, and planning skills. Treatment efficacy was measured using pre- and posttreatment self-report standardized measures (CAARS-S:L & Brown ADD Scales). RESULTS: General linear modeling revealed a robust significant posttreatment decline on the CAARS DSM-IV Inattentive symptom scale (p < .001) as well as improvement on the Brown ADD Scales (p < .001). CONCLUSION: The findings indicate that participants in the MCT program showed marked improvement with respect to core ADHD symptoms of inattention, as well as executive functioning skills, suggesting that this program has promise as a treatment for meta-cognitive deficits in adults with ADHD.

The efficacy of cognitive-behavioral therapy for older adults with ADHD: a randomized controlled trial.

Older adults with ADHD exhibit significant functional impairment, yet there is little research to guide clinicians in evidence-based care of these adults. This study examined response to treatment in older adults who participated in a previous study of the efficacy of cognitive-behavioral treatment (CBT) in adult ADHD. It was hypothesized that older adults would respond less well to CBT than younger adults, given the cognitive demands of the treatment. As described in the original publication, 88 adults who met DSM-IV criteria for ADHD were randomized to receive either a manualized 12-week CBT group intervention targeting executive dysfunction or a parallel Support group. In the current study, outcomes for 26 adults, aged 50 or older, were compared with those of 55 younger adults with respect to inattentive symptoms assessed on a structured interview by a blind clinician, as well as on ratings by self and/or collateral on measures of attention, executive dysfunction, and comorbidity. Contrary to the hypothesis, older and younger adults were equally responsive to CBT on measures of attention. The older adults also responded as well to Support as to CBT on several outcome measures. The results provide preliminary evidence that CBT is an effective intervention for older adults with ADHD. The unexpected response to support highlights a possible age-specificity of effective therapeutic intervention that requires further investigation.

Neurocognitive functioning in AD/HD, predominantly inattentive and combined subtypes.

The Predominantly Inattentive (PI) and Combined (CB) subtypes of AD/HD differ in cognitive tempo, age of onset, gender ratio, and comorbidity, yet a differentiating endophenotype has not been identified. The aim of this study was to test rigorously diagnosed PI, CB, and typical children on measures selected for their potential to reveal hypothesized differences between the subtypes in specific neurocognitive systems (anterior vs. posterior attentional systems) and processes (arousal vs. activation). Thirty-four CB and 26 PI children meeting full DSM-IV criteria for subtype both in school and at home, without confounding reading disability or emotional disorder, were enrolled along with 20 typically developing children. Neurocognitive functions measured included attention, inhibitory control, working memory, learning, and executive functions. Tasks included the Stroop, Wisconsin Card Sorting Test, Continuous Performance Test (CPT). Buschke Selective Reminding Test, ad the Tower of London (TOL), as well as instruments developed by Posner and Sternberg, and tasks assessing the impact on reaction time of [corrected] varying preparatory intervals and stimulus/response complexity. After co-varying for IQ, subtypes differed primarily on measures of impulsivity during tests of vigilance (CPT) and executive function (TOL), with the CB group showing greater impulsivity than both other groups. In addition, the PI group showed worse performance than CB and control groups on the WISC-III Processing Speed Index. Whether analyzed with or without an IQ co-variate, there was no support in the data for hypothesized differences between subtypes in functioning of the anterior vs. posterior attentional systems, nor in involvement of arousal vs. activation processes. The results indicate that the PI and CB subtypes are best differentiated by ratings, observations and tests of cognitive tempo and behavioral impulsivity. Neuropsychological methods have yet to identify critical neuropsychological [corrected] substrates of these differences.

RETRACTED: Sluggish Cognitive Tempo, Internalizing Symptoms, and Executive Function in Adults With ADHD.

Leikauf, J. E., & Solanto, M. V. (2016). Sluggish Cognitive Tempo, Internalizing Symptoms, and Executive Function in Adults With ADHD. Journal of Attention Disorders. Advance online publication. doi: 10.1177/1087054716659361.

Sluggish Cognitive Tempo, Internalizing Symptoms, and Executive Function in Adults With ADHD.

OBJECTIVE: We sought to characterize relationships between sluggish cognitive tempo (SCT) and both internalizing symptoms and executive functioning in adults with ADHD. METHOD: A total of 102 adults with ADHD completed clinical interviews and clinical rating scales. Hierarchical regression analyses were conducted to ascertain the independent predictive power of SCT symptoms for deficits in executive function (EF) after considering severity of ADHD inattentive and hyperactive-impulsive symptoms and internalizing symptoms. RESULTS: SCT correlated with ADHD inattentive symptoms and dimensional measures of depression and anxiety but not with clinical diagnosis of depression or anxiety. SCT predicted EF deficits over and above the effects of internalizing and ADHD symptoms. This relationship between SCT and EF was limited to the subset of participants ( n = 48) receiving stimulant treatment. CONCLUSION: SCT in adults with ADHD is associated with internalizing symptoms, ADHD inattentive symptoms, and, independently, with EF deficits. Further research is needed to ascertain why this relationship occurred primarily in adults concurrently receiving stimulants.

Dopamine dysfunction in AD/HD: integrating clinical and basic neuroscience research.

There is strong evidence that the catecholamines dopamine and norepinephrine are both important in the pathophysiology of ADHD, as well as in the mechanism of therapeutic action of stimulant drugs. Due to the known effects of stimulants in blocking reuptake of catecholamines and (in the case of D-amphetamine) facilitating their release, it has traditionally been believed that the stimulants compensate for catecholamine deficiency in ADHD. More recently, however, alternate hypotheses of a hyperdopaminergic and/or hyper-noradrenergic state in ADHD have been suggested. This paper will be limited to a review of the evidence for involvement of dopamine in mediating behavioral and cognitive symptoms and response to stimulants in ADHD, with implications for possible mechanisms.

The utility of self-report measures and the continuous performance test in the diagnosis of ADHD in adults.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) occurs in as many as 4 percent of adults yet it is often not recognized in clinical settings because the presenting symptoms may resemble those seen in other disorders or because symptoms may be masked by commonly comorbid conditions such as anxiety and depression. OBJECTIVE: The purpose of this study was to examine the diagnostic utility of instruments commonly used in the assessment of adults presenting with symptoms of ADHD. METHODS: We reviewed several widely used self-report and laboratory measures and empirically examined the utility of the Brown Attention-Deficit Disorder Scale for Adults (Brown ADD Scale) and the Conners Continuous Performance Test (CPT) in differentially identifying adults with ADHD and those with other Axis I disorders. RESULTS: Ninety-three adults who self-referred to the ADHD program for adults at a university medical center participated in the study. Of these, 44 had ADHD combined subtype (ADHD-CB), and 26 had ADHD, predominantly inattentive subtype (ADHD-IA). Thirty-three non-ADHD adults diagnosed with Axis I mood or anxiety disorders comprised an "Other Psychiatric" group. Rates of comorbid disorders, including substance abuse, in the ADHD groups were typical of those reported in the adult ADHD literature. Data on the Brown ADD Scale and on the CPT were available for subsets of 61 and 46 participants, respectively. Analyses showed that the ADHD-CB, ADHD-IA, and Other Psychiatric groups all received mean scores in the clinical range on the Brown ADD Scale, with a trend toward even higher elevations in the two ADHD groups. Among 12 CPT variables assessed for the three groups, the mean scores on only two variables for the ADHD-IA group were clinically elevated. Neither the Brown ADD Scale nor CPT scores evinced sufficient sensitivity and specificity to qualify them to assist in differential diagnosis of ADHD vis-a-vis other, predominantly internalizing, psychiatric disorders. CONCLUSION: The results indicate a need for closer examination of executive and adaptive functioning in adults with ADHD compared with those with internalizing disorders in order to identify features that could assist in differential diagnosis.

Adult ADHD vs. bipolar disorder in the DSM-5 era: a challenging differentiation for clinicians.

OBJECTIVE: Patients with adult attention-deficit/ hyperactivity disorder (ADHD) and bipolar disorder can present with similar symptoms, including increased energy, distractibility, disorganization, impulsivity, hyperactivity, and rapid speech. Determining whether the patient has either, or possibly both, of these syndromes can be a complex task. This review attempts to clarify where these disorders overlap, both symptomatically and epidemiologically, and where they diverge, to help clinicians increase the accuracy of their diagnoses. Changes to diagnostic criteria from the fourth to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (from DSM-IV-TR to DSM-5) are discussed, as is the evidence base for pharmacological treatments. METHOD: Studies and sources were identified using computerized searches. RESULTS: Adult ADHD and bipolar disorder have multiple overlapping symptoms, but there are differences in prevalence (ADHD affects 4.4% of adults in the United States versus 1.4% for bipolar disorder), onset of symptoms (usually before age 7 years in ADHD versus after age 12 years in bipolar disorder), disease course (chronic in ADHD versus cyclical in bipolar disorder), mood symptoms (absent in ADHD but always present in bipolar disorder), and psychotic symptoms (absent in ADHD but sometimes present in bipolar disorder). Approximately 20% of adult patients with ADHD also have bipolar disorder, while 10%-20% of patients with bipolar disorder have adult ADHD. Comorbidity of bipolar disorder and ADHD is associated with an earlier age of onset and a more chronic and disabling course of bipolar disorder, as well as more psychiatric comorbidity. CONCLUSION: Distinguishing between adult ADHD and bipolar disorder requires careful attention to phenomenology and awareness of epidemiology, with a focus on childhood history, lifetime course of symptoms, and the possibility of comorbidity.