Effectiveness of collaborative tele-mental health care for children with attention deficit hyperactivity disorder in United Arab Emirates.

Background: Attention deficit hyperactivity disorder is a common neurodevelopmental disorder. Accessing services for this disorder is a worldwide challenge and requires innovative interventions. Aims: We aimed to investigate the effectiveness of tele-collaborative care for attention deficit hyperactivity disorder in primary health care centres in Dubai. Methods: Six trained physicians started collaborative care clinics across Dubai. Eligible children aged 6-12 years attending primary health care centres with attention deficit hyperactivity disorder were randomly selected to receive telehealth collaborative care, or standard treatment. Baseline assessments were conducted using the Vanderbilt Behavioral Assessment Scale, the Columbia Impairment Scale, the Childhood Behavior Checklist, and the Strength and Difficulties Questionnaire. Waiting times and clinical and functional outcomes were measured in both groups and compared. Continuous variables were presented as means and standard deviations, categorical variables such as sex were presented as numbers and percentages, and continuous outcome variables were compared using the Student t-test. Results: Among the referred children (n = 112), 11 boys and 6 girls met the eligibility criteria (mean age 7.8 years). The dropout rate at 6 months in the control group was 80%, compared with 50% in the intervention group. The mean waiting time was significantly shorter in the intervention group (1.3 weeks) than the control group (7.1 weeks); P = 0.026. The mean difference in the Childhood Behavior Checklist total score over time was significantly higher in the intervention group (P = 0.042), but the mean difference in the Vanderbilt scale was not significant. Conclusion: Tele-collaborative care for children with attention deficit hyperactivity disorder within primary health care is feasible.

Association Between Stimulant Treatment and Substance Use Through Adolescence Into Early Adulthood.

Importance: Possible associations between stimulant treatment of attention-deficit/hyperactivity disorder (ADHD) and subsequent substance use remain debated and clinically relevant. Objective: To assess the association of stimulant treatment of ADHD with subsequent substance use using the Multimodal Treatment Study of ADHD (MTA), which provides a unique opportunity to test this association while addressing methodologic complexities (principally, multiple dynamic confounding variables). Design, Setting, and Participants: MTA was a multisite study initiated at 6 sites in the US and 1 in Canada as a 14-month randomized clinical trial of medication and behavior therapy for ADHD but transitioned to a longitudinal observational study. Participants were recruited between 1994 and 1996. Multi-informant assessments included comprehensively assessed demographic, clinical (including substance use), and treatment (including stimulant treatment) variables. Children aged 7 to 9 years with rigorously diagnosed DSM-IV combined-type ADHD were repeatedly assessed until a mean age of 25 years. Analysis took place between April 2018 and February 2023. Exposure: Stimulant treatment of ADHD was measured prospectively from baseline for 16 years (10 assessments) initially using parent report followed by young adult report. Main Outcomes and Measures: Frequency of heavy drinking, marijuana use, daily cigarette smoking, and other substance use were confidentially self-reported with a standardized substance use questionnaire. Results: A total of 579 children (mean [SD] age at baseline, 8.5 [0.8] years; 465 [80%] male) were analyzed. Generalized multilevel linear models showed no evidence that current (B [SE] range, -0.62 [0.55] to 0.34 [0.47]) or prior stimulant treatment (B [SE] range, -0.06 [0.26] to 0.70 [0.37]) or their interaction (B [SE] range, -0.49 [0.70] to 0.86 [0.68]) were associated with substance use after adjusting for developmental trends in substance use and age. Marginal structural models adjusting for dynamic confounding by demographic, clinical, and familial factors revealed no evidence that more years of stimulant treatment (B [SE] range, -0.003 [0.01] to 0.04 [0.02]) or continuous, uninterrupted stimulant treatment (B [SE] range, -0.25 [0.33] to -0.03 [0.10]) were associated with adulthood substance use. Findings were the same for substance use disorder as outcome. Conclusions and Relevance: This study found no evidence that stimulant treatment was associated with increased or decreased risk for later frequent use of alcohol, marijuana, cigarette smoking, or other substances used for adolescents and young adults with childhood ADHD. These findings do not appear to result from other factors that might drive treatment over time and findings held even after considering opposing age-related trends in stimulant treatment and substance use.

Paths to postsecondary education enrollment among adolescents with and without childhood attention-deficit/hyperactivity disorder (ADHD): A longitudinal analysis of symptom and academic trajectories.

We examined developmental trajectories of attention-deficit/hyperactivity disorder (ADHD) symptoms, standardized achievement, and school performance for adolescents with and without ADHD who did and did not enroll in postsecondary education (PSE; N = 749; 79% boys; 63% White, 17% non-Hispanic Black, 10% Hispanic, and 10% other ethnicities). In a multisite study (recruitment based in New York, North Carolina, Pennsylvania, California, and Quebec), participants were originally enrolled between 1994 and 1998 at ages 7 to 9.9 and followed up through 2012 (Mage = 25 at final follow-up). Adolescents who eventually enrolled in PSE had less severe symptoms, but differences were modest and trajectories were similar over time. For all adolescents, standardized achievement trajectories declined up to two thirds of a standard deviation from ages 9 to 17. By the end of high school, the average GPA of adolescents with ADHD was three quarters of a point higher for those who eventually enrolled in PSE compared to those who did not. Overall, school performance mattered more than academic achievement for understanding eventual enrollment of adolescents with ADHD.

Family functioning and mental wellbeing impairment during initial quarantining for the COVID-19 pandemic: A study of Canadian families.

Quarantine measures imposed due to COVID-19 have negatively impacted individual wellbeing. However, the research on the factors impacting mental health and functioning of families is limited. The current study explores socio-economic and demographic factors that mediate poor family functioning, anxiety, and depressive symptoms in response to quarantine measures in Canadian parents and children. 254 Canadian families completed an online questionnaire capturing demographic information and mental wellbeing of individuals and of the whole family. Family functioning was assessed using the Family Assessment Device General Functioning subscale (FAD-GF), and individual mental wellbeing was measured with the Generalized Anxiety Disorder screener (GAD-7) and Patient Health Questionnaire (PHQ-9). Generalized linear models and logistic regression were used to model socio-demographic impacts on outcome variables. Problematic family functioning was found in 78.5% of families with a high proportion of parents reporting above-threshold symptoms of anxiety (62.9%) and depression (73.4%). Many children also reported above-threshold symptoms of anxiety (54.6%) and depression (70.7%). Family functioning was impacted by parent and child age, parental employment status and pre-existing conditions for children. Anxiety and depression experienced by parents and children was increased in families with parents aged <45, household income<$100,000 pre-existing psychiatric conditions, or having a child aged >5 years. These findings show that most Canadian families observed in this study experienced above threshold symptoms of anxiety, depression and poor family functioning. Our study provides an initial step towards identifying characteristics of at-risk families and targeting interventions to mediate negative effects of quarantining.

Variable Patterns of Remission From ADHD in the Multimodal Treatment Study of ADHD.

OBJECTIVE: It is estimated that childhood attention deficit hyperactivity disorder (ADHD) remits by adulthood in approximately 50% of cases; however, this conclusion is typically based on single endpoints, failing to consider longitudinal patterns of ADHD expression. The authors investigated the extent to which children with ADHD experience recovery and variable patterns of remission by adulthood. METHODS: Children with ADHD (N=558) in the Multimodal Treatment Study of ADHD (MTA) underwent eight assessments over follow-ups ranging from 2 years (mean age, 10.44 years) to 16 years (mean age, 25.12 years) after baseline. The authors identified participants with fully remitted, partially remitted, and persistent ADHD at each time point on the basis of parent, teacher, and self-reports of ADHD symptoms and impairment, treatment utilization, and substance use and mental disorders. Longitudinal patterns of remission and persistence were identified that considered context and timing. RESULTS: Approximately 30% of children with ADHD experienced full remission at some point during the follow-up period; however, a majority of them (60%) experienced recurrence of ADHD after the initial period of remission. Only 9.1% of the sample demonstrated recovery (sustained remission) by study endpoint, and only 10.8% demonstrated stable ADHD persistence across study time points. Most participants with ADHD (63.8%) had fluctuating periods of remission and recurrence over time. CONCLUSIONS: The MTA findings challenge the notion that approximately 50% of children with ADHD outgrow the disorder by adulthood. Most cases demonstrated fluctuating symptoms between childhood and young adulthood. Although intermittent periods of remission can be expected in most cases, 90% of children with ADHD in MTA continued to experience residual symptoms into young adulthood.

Review: Adult Outcome as Seen Through Controlled Prospective Follow-up Studies of Children With Attention-Deficit/Hyperactivity Disorder Followed Into Adulthood.

OBJECTIVE: To describe adult outcome of people with attention-deficit/hyperactivity disorder (ADHD) diagnosed in childhood and its several key predictors via a review of 7 North American controlled prospective follow-up studies: Montreal, New York, Milwaukee, Pittsburgh, Massachusetts General Hospital (MGH), Berkeley, and 7-site Multimodal Treatment Study of Children With ADHD (MTA). METHOD: All studies were prospective and followed children with a diagnosis of ADHD and an age- and gender-matched control group at regular intervals from childhood (6-12 years of age) through adolescence into adulthood (20-40 years of age), evaluating symptom and syndrome persistence, functional outcomes, and predictors of these outcomes. RESULTS: The rates of ADHD syndrome persistence ranged from 5.7% to 77%, likely owing to varying diagnostic criteria and the source of information (self-report vs informant report) across the studies. However, all studies observed high rates of symptomatic persistence ranging from 60% to 86%. The 7 studies were largely consistent in finding that relative to control groups, research participants with childhood-diagnosed ADHD had significant impairments in the areas of educational functioning, occupational functioning, mental health, and physical health as well as higher rates of substance misuse, antisocial behavior, and unsafe driving. The most consistently observed predictors of functional outcomes included ADHD persistence and comorbidity, especially with disruptive behavior disorders. CONCLUSION: Childhood ADHD has high rates of symptomatic persistence, which is associated with negative functional outcomes. Characteristics that predict these negative outcomes, such as comorbid disruptive behavior disorders, may be important targets for intervention.

A Qualitative Analysis of Contextual Factors Relevant to Suspected Late-Onset ADHD.

Objective: Recent studies suggest attention-deficit/hyperactivity disorder (ADHD) may emerge post-childhood. We integrate qualitative methods to systematically characterize contextual factors that may (a) delay identification of ADHD in childhood and (b) inform why ADHD symptoms emerge post-childhood. Method: Suspected late-onset ADHD cases from the local normative comparison group of the Multimodal Treatment Study of ADHD completed a qualitative interview (14 young adults and 7 caregivers). Interviews were qualitatively analyzed. Results: We identified five themes. Three themes may attenuate or delay identification of childhood ADHD: external factors (e.g., supportive adults), internal factors (e.g., strong intellectual functioning), and other factors (e.g., dismissive attitudes toward ADHD). Two themes may accompany an increase in ADHD symptoms post-childhood: external factors (e.g., increased external demands) and internal factors (e.g., perceived stress). Conclusion: Clinicians should probe these factors in suspected late-onset cases to address (a) whether, how, and to what extent ADHD was attenuated in childhood and (b) why symptoms emerge post-childhood.

Trajectories of Growth Associated With Long-Term Stimulant Medication in the Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder.

OBJECTIVE: To estimate long-term stimulant treatment associations on standardized height, weight, and body mass index trajectories from childhood to adulthood in the Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder (MTA). METHOD: Of 579 children with DSM-IV ADHD-combined type at baseline (aged 7.0-9.9 years) and 289 classmates (local normative comparison group [LNCG]), 568 and 258 respectively, were assessed 8 times over 16 years (final mean age = 24.7). Parent interview data established subgroups with self-selected Consistent (n = 53, 9%), Inconsistent (n = 374, 66%), and Negligible (n = 141, 25%) stimulant medication use, as well as patients starting stimulants prior to MTA entry (n = 211, 39%). Height and weight growth trajectories were calculated for each subgroup. RESULTS: Height z scores trajectories differed among subgroups (F = 2.22, p < .0001) and by stimulant use prior to study entry (F = 2.22, p < .001). The subgroup-by-assessment interaction was significant (F = 2.81, p < .0001). Paired comparisons revealed significant subgroup differences at endpoint: Consistent was shorter than Negligible (-0.66 z units /-4.06 cm /1.6 inches, t = -3.17, p < 0.0016), Consistent shorter than Inconsistent (-0.45 z units /-2.74 cm /-1.08 inches, t = -2.39, p < .0172), and the Consistent shorter than LNCG (-0.54 z units/+3.34 cm/ 1.31 inches, t = -3.30, p < 0.001). Weight z scores initially diverged among subgroups, converged in adolescence, and then diverged again in adulthood when the Consistent outweighed the LNCG (+ 3.561 z units /+7.47 kg /+16.46 lb, p < .0001). CONCLUSION: Compared with those negligibly medicated and the LNCG, 16 years of consistent stimulant treatment of children with ADHD in the MTA was associated with changes in height trajectory, a reduction in adult height, and an increase in weight and body mass index. CLINICAL TRIAL REGISTRATION INFORMATION: Multimodal Treatment Study of Children With Attention Deficit and Hyperactivity Disorder (MTA); https://clinicaltrials.gov/; NCT00000388.

Effects of Childhood and Adult Persistent Attention-Deficit/Hyperactivity Disorder on Risk of Motor Vehicle Crashes: Results From the Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder.

OBJECTIVE: To determine motor vehicle crash (MVC) risk in adults with a history of childhood attention-deficit/hyperactivity disorder (ADHD) and persistent ADHD symptoms. METHOD: Participants with (n = 441) and without (n = 239; local normative comparison group) childhood ADHD from the Multimodal Treatment of Attention-Deficit/Hyperactivity Disorder (MTA) Study were included. Participants provided self-reports on total number of MVCs they had been involved in and the time of licensure. Driving experience was estimated as the number of months since licensure. Total number of MVCs by adulthood was regressed on baseline ADHD status adjusting for sex, age at follow-up, driving experience, baseline oppositional defiant disorder/conduct disorder comorbidity, baseline household income level, adult oppositional defiant disorder/conduct disorder symptoms, adolescent and adult substance use, and adult antisocial personality disorder symptoms. We repeated the analysis using adult ADHD status (persistent versus desistant versus local normative comparison group) and symptom level as the predictor variables. Results are presented as incidence rate ratio (IRR) and CI. RESULTS: Childhood ADHD was associated with a higher number of MVCs (IRR = 1.45, CI = 1.15-1.82), and adult ADHD symptom persistence was associated with more MVCs than desistance (IRR = 1.46, CI = 1.14-1.86). ADHD desistance was not associated with a significantly increased risk for MVCs compared with the local normative comparison group (IRR = 1.24, CI = 0.96-1.61). Concurrent symptoms of inattention and hyperactivity/impulsivity predicted MVC risk. CONCLUSION: Persistence of ADHD into adulthood is a stronger predictor of MVC risk than childhood-limited ADHD. CLINICAL TRIAL REGISTRATION INFORMATION: Multimodal Treatment of Attention Deficit Hyperactivity Disorder (MTA) Study; https://clinicaltrials.gov; NCT00000388.

Efficacy of Cognitive Behavioral Therapy With and Without Medication for Adults With ADHD: A Randomized Clinical Trial.

Objective: Recent trials have demonstrated efficacy of cognitive behavioral therapy (CBT) in medicated adults with ADHD. Efficacy of CBT in unmedicated versus medicated adults remains mostly unknown. We evaluated the effects of group CBT alone versus combined with medication on ADHD symptoms and functional outcomes in adult patients. Method: Eighty-eight adults with ADHD received 12 manualized group CBT sessions, accompanied by individual coaching, either without (n = 46) or with (n = 42) medication. Treatment effects were evaluated following treatment and 3-month and 6-month follow-up using un-blinded self-report and observer ratings. Results: CBT + medication resulted in greater improvements than CBT alone in ADHD symptoms, organizational skills, and self-esteem. Group differences diminished over follow-up, as the CBT alone group continued improving, while the combined group maintained the gains. Conclusion: CBT + medication outperformed CBT alone for ADHD symptoms, organizational skills, and self-esteem, although its superiority tended to decrease over follow-up.

Maternal personality traits moderate treatment response in the Multimodal Treatment Study of attention-deficit/hyperactivity disorder.

Some mothers of children with attention-deficit/hyperactivity disorder (ADHD) present with maladaptive personality profiles (high neuroticism, low conscientiousness). The moderating effect of maternal personality traits on treatment outcomes for childhood ADHD has not been examined. We evaluate whether maternal neuroticism and conscientiousness moderated response in the Multimodal Treatment Study of Children with ADHD. This is one of the first studies of this type. In a randomized controlled trial (RCT), 579 children aged 7-10 (M = 8.5); 19.7% female; 60.8% White with combined-type ADHD were randomly assigned to systematic medication management (MedMgt) alone, comprehensive multicomponent behavioral treatment (Beh), their combination (Comb), or community comparison treatment-as-usual (CC). Latent class analysis and linear mixed effects models included 437 children whose biological mothers completed the NEO Five-Factor Inventory at baseline. A 3-class solution demonstrated best fit for the NEO: MN&MC = moderate neuroticism and conscientiousness (n = 284); HN&LC = high neuroticism, low conscientiousness (n = 83); LN&HC = low neuroticism, high conscientiousness (n = 70). Per parent-reported symptoms, children of mothers with HN&LC, but not LN&HC, had a significantly better response to Beh than to CC; children of mothers with MN&MC and LN&HC, but not HN&LC, responded better to Comb&MedMgt than to Beh&CC. Per teacher-reported symptoms, children of mothers with HN&LC, but not LN&HC, responded significantly better to Comb than to MedMgt. Children of mothers with high neuroticism and low conscientiousness benefited more from behavioral treatments (Beh vs. CC; Comb vs. MedMgt) than other children. Evaluation of maternal personality may aid in treatment selection for children with ADHD, though additional research on this topic is needed.

Potential Social and Neurocognitive Benefits of Aerobic Exercise as Adjunct Treatment for Patients With ADHD.

Objective: The aim of the article is to review the evidence that aerobic exercise may be a useful adjunct treatment for ADHD. Method: Studies on physical, cognitive, and psychosocial aspects of aerobic exercise that are relevant to ADHD are reviewed and evaluated. Results: Stimulant medication, the main pharmacotherapy for ADHD, and aerobic exercise both act on catecholamine pathways. Aerobic exercise has been shown to be beneficial in preclinical studies on spontaneous hypertensive rats, an animal model of ADHD, and in clinical trials of children with ADHD, as an adjunct treatment to medication. Social and neurocognitive function in children and adults seem to be positively affected by exercise as well. Nevertheless, no controlled clinical trials in adults with ADHD have been conducted. Conclusion: Aerobic exercise may be a useful non-medication adjunct therapy for ADHD. The clinical effectiveness of aerobic exercise for ADHD in children and adults warrants further clinical studies.

Childhood ADHD and Involvement in Early Pregnancy: Mechanisms of Risk.

Objective: ADHD is associated with risky sexual behavior and early pregnancy, but few studies have examined mechanisms of risk linking childhood ADHD to early pregnancy. The present study utilized data from the Multimodal Treatment Study of ADHD to examine potential mechanisms that may account for the association between childhood ADHD and becoming pregnant or causing a pregnancy by age 18. Method: Participants were 579 children with ADHD and 289 comparison peers followed over 16 years. Results: Relative to the comparison group, those with childhood ADHD were at more than two times increased risk of early pregnancy. Univariately, persistence of ADHD symptoms, delinquency/substance use, and academic performance/achievement during adolescence each mediated the association between childhood ADHD and early pregnancy. When considered together, only delinquency/substance use remained a significant mediator of this relationship. Conclusion: Findings point toward specific targets of intervention for youth with ADHD to prevent early pregnancy.

Adult substance use as a function of growth in peer use across adolescence and young adulthood in the context of ADHD: Findings from the MTA.

Peer substance use strongly predicts adolescent and young adult substance use, but its role in ADHD-related risk for substance use, especially in adulthood, is unclear. In a sample with (n = 516) and without (n = 249) childhood ADHD from the Multimodal Treatment Study of ADHD, we compared associations between change over time in peer substance use and personal substance use (alcohol, cigarettes, marijuana, illicit drugs) from age 14-26 by ADHD status. Developmentally typical peer substance use trajectories across adolescence and young adulthood coincided with similar changes in personal use - but less so for those with ADHD histories. Concurrent associations between peer and personal use in adolescence and young adulthood were weaker for those with ADHD histories than without for commonly used substances (alcohol, marijuana). Prospectively, escalating peer use during adolescence forecasted adulthood declines for commonly used substances, yet persistently high substance use at age 25, regardless of ADHD history. In the reverse direction, growth in adolescent substance use predicted developmentally normative young adult declines in peer use - but for the ADHD group, adolescent heavy drinking predicted increases in young adult peer use. Findings suggest that individuals with ADHD may have difficulty emulating their peers' developmentally normative declines in substance use, highlighting the importance of social factors when treating young adults affected by ADHD and substance abuse.

Cigarette Smoking Progression Among Young Adults Diagnosed With ADHD in Childhood: A 16-year Longitudinal Study of Children With and Without ADHD.

INTRODUCTION: Children with attention-deficit/hyperactivity disorder (ADHD) are at increased risk for smoking cigarettes, but there is little longitudinal research on the array of smoking characteristics known to be prognostic of long-term smoking outcomes into adulthood. These variables were studied into early adulthood in a multisite sample diagnosed with ADHD combined type at ages 7-9.9 and followed prospectively alongside an age- and sex-matched local normative comparison group (LNCG). METHODS: Cigarette smoking quantity, quit attempts, dependence, and other characteristics were assessed in the longitudinal Multimodal Treatment Study of Children with ADHD (MTA) eight times to a mean age of 24.9 years: ADHD n = 469; LNCG n = 240. RESULTS: In adulthood, the ADHD group had higher rates of daily cigarette smoking, one or more quit attempts, shorter time to first cigarette of the day, and more severe withdrawal than the LNCG. The ADHD group did not appear to have better smoking cessation rates despite a higher proportion quitting at least once. Smoking quantity and nicotine dependence did not differ between groups. The ADHD group reported younger daily smoking onset and faster progression from smoking initiation to daily smoking across assessments. Finally, ADHD symptom severity in later adolescence and adulthood was associated with higher risk for daily smoking across assessments in the ADHD sample. CONCLUSIONS: This study shows that ADHD-related smoking risk begins at a young age, progresses rapidly, and becomes resistant to cessation attempts by adulthood. Prevention efforts should acknowledge the speed of uptake; treatments should target the higher relapse risk in this vulnerable population. IMPLICATIONS: Although childhood ADHD predicts later smoking, longitudinal studies of this population have yet to fully characterize smoking behaviors into adulthood that are known to be prognostic of long-term smoking outcome. The current study demonstrates earlier and faster progression to daily smoking among those with a childhood ADHD diagnosis, as well as greater risk for failed quit attempts. Prevention efforts should address speed of smoking uptake, while treatments are needed that address smoking relapse risk. The current study also demonstrates ADHD symptom severity over development increases daily smoking risk, implicating the need for continuous ADHD symptom management.

Predictive utility of childhood diagnosis of ICD-10 hyperkinetic disorder: adult outcomes in the MTA and effect of comorbidity.

Diagnostic guidelines differ between DSM attention-deficit/hyperactivity disorder (ADHD) and ICD hyperkinetic disorder (HKD). Only 145 of 579 children age 7-9 in the Multimodal Treatment Study of ADHD (the MTA) with combined-type DSM-IV ADHD met criteria for ICD-10 HKD, because major internalizing comorbidities and more stringent symptom count/pervasiveness requirements excluded most. The 145 HKD had significantly better 14-month medication response than the rest. We explored whether HKD had greater adult symptom persistence and/or impairment than other ADHD. Multi-informant assessments were done for 16 years. We used the 12/14/16-year assessments, in young adulthood. The post-attrition 109 with baseline HKD had no greater adult persistence of ADHD symptoms/impairment than 367 without HKD, but had more cumulative stimulant use, more job losses, lower emotional lability, and fewer car crashes. However, those excluded for internalizing comorbidity but otherwise meeting HKD criteria had significantly more persistence. Only 6 of the 109 (5.5%) with baseline HKD met ICD-10 criteria for HKD in adulthood, compared to 25 of 367 (6.8%) without a childhood HKD diagnosis. Despite greater initial symptom severity, HKD had no worse 16-year young adult outcome than others, except for job losses, balanced by less emotional lability and fewer crashes. Comorbid internalizing disorder seems to have worse prognosis than initial severity/pervasiveness of ADHD symptoms.