Home-based brain-computer interface attention training program for attention deficit hyperactivity disorder: a feasibility trial.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is a prevalent child neurodevelopmental disorder that is treated in clinics and in schools. Previous trials suggested that our brain-computer interface (BCI)-based attention training program could improve ADHD symptoms. We have since developed a tablet version of the training program which can be paired with wireless EEG headsets. In this trial, we investigated the feasibility of delivering this tablet-based BCI intervention at home. METHODS: Twenty children diagnosed with ADHD, who did not receive any medication for the preceding month, were randomised to receive the 8-week tablet-based BCI intervention either in the clinic or at home. Those in the home intervention group received instructions before commencing the program and got reminders if they were lagging on the training sessions. The ADHD Rating Scale was completed by a blinded clinician at baseline and at week 8. Adverse events were monitored during any contact with the child throughout the trial and at week 8. RESULTS: Children in both groups could complete the tablet-based intervention easily on their own with minimal support from the clinic therapist or their parents (at home). The intervention was safe with few reported adverse effects. Clinician-rated inattentive symptoms on the ADHD-Rating Scale reduced by 3.2 (SD 6.20) and 3.9 (SD 5.08) for the home-based and clinic-based groups respectively, suggesting that home-based intervention was comparable to clinic-based intervention. CONCLUSIONS: This trial demonstrated that the tablet version of our BCI-based attention training program can be safely delivered to children in the comfort of their own home. Trial registration This trial is registered at clinicaltrials.gov as NCT01344044.

Social Deficits or Interactional Differences? Interrogating Perspectives on Social Functioning in Autism.

Social dysfunction is a key characteristic of autism. Determining and treating autism-related social deficits have been challenging. The medical model views interpersonal difficulties in autism as a localized set of deficits to be managed, whereas the neurodiversity movement calls for the accommodation of differences by the larger community. One common assumption underlying these perspectives is a misalignment in social behaviors between autistic individuals and neurotypicals. This paper reviews and interrogates current perspectives on social functioning in autism to uncover the intricacies of such a notion. Even though extant literature has alluded to a misalignment in social behaviors between autistic and neurotypical individuals, it is uncertain where this disparity lies. Implications for future research and practice are discussed.

Gender differences in externalizing and internalizing problems in Singaporean children and adolescents with attention-deficit/hyperactivity disorder.

BACKGROUND: Studies on gender differences in attention-deficit/hyperactivity disorder (ADHD) comorbidities in the Asian populations have been limited and previous studies have shown inconclusive findings. Singapore is a city-state country in Southeast Asia with a population of 5.7 million. This study examined gender differences in internalizing and externalizing problems in Singaporean children and adolescents with ADHD. The plausible social factors underlying the gender differences were discussed. METHODS: A total of 773 participants (aged 6 to 18, 88% males) newly diagnosed with ADHD were recruited from the largest public child and adolescent psychiatric center in Singapore. Their internalizing and externalizing problems were assessed using the Child Behavioral Checklist and Teacher's Report Form by parents and teachers respectively. Demographics and relevant social factors were collected using parent questionnaires. RESULTS: Females with ADHD were reported to have less delinquent and aggressive behavior but more depressive symptoms than their male counterparts, similar to findings in the Western literature. Gender remained a significant predictor of externalizing problem after controlling for other factors. Lower socioeconomic status and parental use of physical punishment were significant predictors of both internalizing and externalizing problems. CONCLUSIONS: Gender differences in ADHD comorbidities do exist in the Asian clinical population. The lack of externalizing symptoms in females with ADHD has made timely referral and diagnosis challenging. More research is needed in understanding the gender differences in ADHD and the biopsychosocial mechanism underlying the differences in order to improve the detection of ADHD in females.

The Effects of a Traditional Chinese Medication on Children with Attention-Deficit/Hyperactivity Disorder.

Objective: This feasibility study examined the effects of a particular Traditional Chinese Medicine (TCM) herbal formula on attention-deficit/hyperactivity disorder (ADHD) and related problem behaviors. Design: A total of 79 participants aging 6-12 years consumed a granulated TCM herbal formula twice daily over a period of 3 months and underwent assessments at months 0, 3, and 6. Changes in ADHD symptoms and related behaviors were measured using the ADHD rating scale-IV (ADHD-RS-IV), child behavior checklist (CBCL), children's global sssessment scale (CGAS), as well as the clinical global impressions-severity (CGI-S) and improvement (CGI-I) scales. Results: Repeated measures mixed model analyses revealed significant differences in scores across time on all ADHD-RS-IV and CBCL subscales as well as on the CGAS, CGI-S, and CGI-I scales. Pairwise comparisons between months 0 and 3 as well as months 0 and 6 indicated significant improvements in scores. Scores also did not differ significantly between months 3 and 6. The results may suggest that this particular TCM formula possesses potential therapeutic qualities in the treatment of ADHD. Furthermore, changes in ADHD symptoms generally appear to be stable 3 months after discontinuation. However, these findings could also be attributed to placebo effects as well as reporting biases. Conclusion: This particular TCM formula may prove to be a useful adjunctive treatment for children with ADHD, and randomized controlled trials need to be conducted to evaluate its efficacy.

Recent developments in the intervention of specific phobia among adults: a rapid review.

Specific phobia is highly prevalent worldwide. Although the body of intervention studies is expanding, there is a lack of reviews that summarise recent progress and discuss the challenges and direction of research in this area. Hence, this rapid review seeks to systematically evaluate the available evidence in the last five years in the treatment of specific phobias in adults. Studies published between January 2014 to December 2019 were identified through searches on the electronic databases of Medline and PsychINFO. In total, 33 studies were included. Evidence indicates that psychotherapy, and in particular cognitive behaviour therapy, when implemented independently or as an adjunctive, is a superior intervention with large effect sizes. Technology-assisted therapies seem to have a beneficial effect on alleviating fears and are described to be more tolerable than in vivo exposure therapy. Pharmacological agents are investigated solely as adjuncts to exposure therapy, but the effects are inconsistent; propranolol and glucocorticoid may be promising. A handful of cognitive-based therapies designed to alter fear arousal and activation pathways of phobias have presented preliminary, positive outcomes. Challenges remain with the inherent heterogeneity of specific phobia as a disorder and the accompanying variability in outcome measures and intervention approaches to warrant a clear conclusion on efficacy.

A randomized controlled trial of a brain-computer interface based attention training program for ADHD.

OBJECTIVE: The use of brain-computer interface in neurofeedback therapy for attention deficit hyperactivity disorder (ADHD) is a relatively new approach. We conducted a randomized controlled trial (RCT) to determine whether an 8-week brain computer interface (BCI)-based attention training program improved inattentive symptoms in children with ADHD compared to a waitlist-control group, and the effects of a subsequent 12-week lower-intensity training. STUDY DESIGN: We randomized 172 children aged 6-12 attending an outpatient child psychiatry clinic diagnosed with inattentive or combined subtypes of ADHD and not receiving concurrent pharmacotherapy or behavioral intervention to either the intervention or waitlist-control group. Intervention involved 3 sessions of BCI-based training for 8 weeks, followed by 3 training sessions per month over the subsequent 12 weeks. The waitlist-control group received similar 20-week intervention after a wait-time of 8 weeks. RESULTS: The participants' mean age was 8.6 years (SD = 1.51), with 147 males (85.5%) and 25 females (14.5%). Modified intention to treat analyzes conducted on 163 participants with at least one follow-up rating showed that at 8 weeks, clinician-rated inattentive symptoms on the ADHD-Rating Scale (ADHD-RS) was reduced by 3.5 (SD 3.97) in the intervention group compared to 1.9 (SD 4.42) in the waitlist-control group (between-group difference of 1.6; 95% CI 0.3 to 2.9 p = 0.0177). At the end of the full 20-week treatment, the mean reduction (pre-post BCI) of the pooled group was 3.2 (95% CI 2.4 to 4.1). CONCLUSION: The results suggest that the BCI-based attention training program can improve ADHD symptoms after a minimum of 24 sessions and maintenance training may sustain this improvement. This intervention may be an option for treating milder cases or as an adjunctive treatment.

Omega-3 (ω-3) and social skills interventions for reactive aggression and childhood externalizing behavior problems: a randomized, stratified, double-blind, placebo-controlled, factorial trial.

BACKGROUND: While studies suggest that nutritional supplementation may reduce aggressive behavior in children, few have examined their effects on specific forms of aggression. This study tests the primary hypothesis that omega-3 (ω-3), both alone and in conjunction with social skills training, will have particular post-treatment efficacy for reducing childhood reactive aggression relative to baseline. METHODS: In this randomized, double-blind, stratified, placebo-controlled, factorial trial, a clinical sample of 282 children with externalizing behavior aged 7-16 years was randomized into ω-3 only, social skills only, ω-3 + social skills, and placebo control groups. Treatment duration was 6 months. The primary outcome measure was reactive aggression collected at 0, 3, 6, 9, and 12 months, with antisocial behavior as a secondary outcome. RESULTS: Children in the ω-3-only group showed a short-term reduction (at 3 and 6 months) in self-report reactive aggression, and also a short-term reduction in overall antisocial behavior. Sensitivity analyses and a robustness check replicated significant interaction effects. Effect sizes (d) were small, ranging from 0.17 to 0.31. CONCLUSIONS: Findings provide some initial support for the efficacy of ω-3 in reducing reactive aggression over and above standard care (medication and parent training), but yield only preliminary and limited support for the efficacy of ω-3 in reducing overall externalizing behavior in children. Future studies could test further whether ω-3 shows promise in reducing more reactive, impulsive forms of aggression.

Large-scale brain functional network topology disruptions underlie symptom heterogeneity in children with attention-deficit/hyperactivity disorder.

Accumulating evidence suggests brain network dysfunction in attention-deficit/hyperactivity disorder (ADHD). Whether large-scale brain network connectivity patterns reflect clinical heterogeneity in ADHD remains to be fully understood. This study aimed to characterize the differential within- and between-network functional connectivity (FC) changes in children with ADHD combined (ADHD-C) or inattentive (ADHD-I) subtypes and their associations with ADHD symptoms. We studied the task-free functional magnetic resonance imaging (fMRI) data of 58 boys with ADHD and 28 demographically matched healthy controls. We measured within- and between-network connectivity of both low-level (sensorimotor) and high-level (cognitive) large-scale intrinsic connectivity networks and network modularity. We found that children with ADHD-C but not those with ADHD-I exhibited hyper-connectivity within the anterior default mode network (DMN) compared with controls. Additionally, children with ADHD-C had higher inter-network FC between the left executive control (ECN) and the salience (SN) networks, between subcortical and visual networks, and between the DMN and left auditory networks than controls, while children with ADHD-I did not show differences compared with controls. Similarly, children with ADHD-C but not ADHD-I showed lower network modularity compared with controls. Importantly, these observed abnormal inter-network connectivity and network modularity metrics were associated with Child Behavioral Checklist (CBCL) attention-deficit/hyperactivity problems and internalizing problems in children with ADHD. This study revealed relatively greater loss of brain functional network segregation in childhood ADHD combined subtype compared to the inattentive subtype, suggesting differential large-scale functional brain network topology phenotype underlying childhood ADHD heterogeneity.

Brain-computer-interface-based intervention re-normalizes brain functional network topology in children with attention deficit/hyperactivity disorder.

A brain-computer-interface (BCI)-based attention training game system has shown promise for treating attention deficit/hyperactivity disorder (ADHD) children with inattentive symptoms. However, little is known about brain network organizational changes underlying behavior improvement following BCI-based training. To cover this gap, we aimed to examine the topological alterations of large-scale brain functional networks induced by the 8-week BCI-based attention intervention in ADHD boys using resting-state functional magnetic resonance imaging method. Compared to the non-intervention (ADHD-NI) group, the intervention group (ADHD-I) showed greater reduction of inattention symptoms accompanied with differential brain network reorganizations after training. Specifically, the ADHD-NI group had increased functional connectivity (FC) within the salience/ventral attention network (SVN) and increased FC between task-positive networks (including the SVN, dorsal attention (DAN), somatomotor, and executive control network) and subcortical regions; in contrast ADHD-I group did not have this pattern. In parallel, ADHD-I group had reduced degree centrality and clustering coefficient as well as increased closeness in task-positive and the default mode networks (prefrontal regions) after the training. More importantly, these reduced local functional processing mainly in the SVN were associated with less inattentive/internalizing problems after 8-week BCI-based intervention across ADHD patients. Our findings suggest that the BCI-based attention training facilitates behavioral improvement in ADHD children by reorganizing brain functional network from more regular to more random configurations, particularly renormalizing salience network processing. Future long-term longitudinal neuroimaging studies are needed to develop the BCI-based intervention approach to promote brain maturation in ADHD.

Child Community Mental Health Services in Asia Pacific and Singapore's REACH Model.

In recent decades, there have been concerted efforts to improve mental health services for youths alongside the challenges of rising healthcare costs and increasing demand for mental health needs. One important phenomenon is the shift from traditional clinic-based care to community-based mental health services to improve accessibility to services and provide patient-centred care. In this article, we discuss the child and adolescent community mental health efforts within the Asia-Pacific region. We also discuss Singapore's community and school-based mental health service, known as the Response, Early Intervention and Assessment in Community Mental Health (REACH). This article discusses how REACH has evolved over the years in response to the changing needs of youths in Singapore. Finally, we discuss the current challenges and future directions for youth mental health care.

Intrinsic Affective Network Is Impaired in Children with Attention-Deficit/Hyperactivity Disorder.

Deficits in impulsivity and affect dysregulation are key features of attention-deficit/hyperactivity disorder (ADHD) besides impairing levels of hyperactivity and/or inattention. However, the neural substrates underlying these traits are relatively under-investigated. In this study, we use resting-state functional magnetic resonance imaging to test the hypothesis of diminished functional integration within the affective/limbic network (which includes the amygdala, hippocampus, subgenual cingulate cortex, orbitofrontal cortex and nucleus accumbens) of children with ADHD, which is associated with their behavioral measures of emotional control deficits. Resting state-fMRI data were obtained from 12 healthy control subjects and 15 children with ADHD, all who had a minimum one-month washout period for medications and supplements. Children with ADHD demonstrated less integrated affective network, evidenced by increased bilateral amygdalar and decreased left orbitofrontal connectivity within the affective network compared to healthy controls. The hyper-connectivity at the left amygdalar within the affective network was associated with increased aggressiveness and conduct problems, as well as decline in functioning in children with ADHD. Similar findings in affective network dysconnectivity were replicated in a subset of children with ADHD three months later. Our findings of divergent changes in amygdala and orbitofrontal intrinsic connectivity support the hypothesis of an impaired functional integration within the affective network in childhood ADHD. Larger prospective studies of the intrinsic affective network in ADHD are required, which may provide further insight on the biological mechanisms of emotional control deficits observed in ADHD.

Child and adolescent psychiatry services in Singapore.

Singapore is a small young city state with a multi-ethnic and multi-cultural population. This article reviews the development of the country's child and adolescent psychiatry services through the years, in the background of other developments within the country's education, social and legal services. Research and other available data on the prevalence of psychiatric problems among children and adolescents in Singapore are summarized, although there has been no nation-wide epidemiological study done. One of the most recent developments has been the establishment of a community mental health service, which works collaboratively with schools and community partners. Some challenges are also discussed especially in the area of child and adolescent psychiatry training. Possible future directions include providing mental heath care for preschool children as well as epidemiological studies to identify disease prevalence and mental health needs among children and adolescents in Singapore.

Academy of Medicine-Ministry of Health clinical practice guidelines: attention deficit hyperactivity disorder.

The Academy of Medicine (AMS) and the Ministry of Health (MOH) have developed the clinical practice guidelines on Attention Deficit Hyperactivity Disorder (ADHD) to provide doctors and patients in Singapore with evidence-based treatment for ADHD. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on ADHD, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html.The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

What's in the pipeline? Drugs in development for autism spectrum disorder.

Autism Spectrum Disorder (ASD) is a complex neurodevelopmental disorder with both core symptoms and associated symptoms (eg, irritability, aggression, and comorbidities) that affect both the individual and the family/systems around them. There have been recent advances in the understanding of the underlying pathophysiology of ASD pertaining to genetics, epigenetics, neurological, hormonal, and environmental factors that contribute to the difficulties found in individuals with ASD. With this improved understanding, there has been a shift in the application of psychopharmacology in ASD and its related disorders. A literature review was conducted to examine research published in the last 5 years between different classes of psychotropic medications and ASD. The broad scope of the existing literature for the use of conventional medications is summarized and novel medications are discussed.

Interventions for preschool children at high risk for ADHD: a comparative effectiveness review.

OBJECTIVES: The US Agency for Healthcare Research and Quality sponsored a comparative effectiveness review of interventions for preschoolers at risk for attention-deficit/hyperactivity disorder (ADHD). METHODS: Medline, Cochrane CENTRAL, Embase, PsycInfo, and Education Resources Information Center were searched from 1980 to November 24, 2011. Selected studies were comparative, and enrolled children <6 years with clinically significant disruptive behavior, including ADHD. The interventions evaluated were parent behavior training (PBT), combined home and school/day care interventions, and methylphenidate use. Data were extracted by using customized software. Two independent raters evaluated studies as good, fair, or poor by using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies Risk of Bias. Overall strength of evidence (SOE) was rated for each intervention's effectiveness, accounting for study design, systematic error, consistency of results, directness of evidence, and certainty regarding outcome. RESULTS: Fifty-five studies were examined. Only studies examining PBT interventions could be pooled statistically using meta-analysis. Eight "good" studies examined PBT, total n = 424; SOE was high for improved child behavior, standardized mean difference = -0.68 (95% confidence interval: -0.88 to -0.47), with minimal heterogeneity among studies. Only 1 good study evaluated methylphenidate, total n = 114; therefore, SOE for methylphenidate was low. Combined home and school/day care interventions showed inconsistent results. The literature reported adverse effects for methylphenidate but not for PBT. CONCLUSIONS: With more studies consistently documenting effectiveness, PBT interventions have greater evidence of effectiveness than methylphenidate for treatment of preschoolers at risk for ADHD.

A brain-computer interface based attention training program for treating attention deficit hyperactivity disorder.

UNLABELLED: Attention deficit hyperactivity disorder (ADHD) symptoms can be difficult to treat. We previously reported that a 20-session brain-computer interface (BCI) attention training programme improved ADHD symptoms. Here, we investigated a new more intensive BCI-based attention training game system on 20 unmedicated ADHD children (16 males, 4 females) with significant inattentive symptoms (combined and inattentive ADHD subtypes). This new system monitored attention through a head band with dry EEG sensors, which was used to drive a feed forward game. The system was calibrated for each user by measuring the EEG parameters during a Stroop task. Treatment consisted of an 8-week training comprising 24 sessions followed by 3 once-monthly booster training sessions. Following intervention, both parent-rated inattentive and hyperactive-impulsive symptoms on the ADHD Rating Scale showed significant improvement. At week 8, the mean improvement was -4.6 (5.9) and -4.7 (5.6) respectively for inattentive symptoms and hyperactive-impulsive symptoms (both p<0.01). Cohen's d effect size for inattentive symptoms was large at 0.78 at week 8 and 0.84 at week 24 (post-boosters). Further analysis showed that the change in the EEG based BCI ADHD severity measure correlated with the change ADHD Rating Scale scores. The BCI-based attention training game system is a potential new treatment for ADHD. TRIAL REGISTRATION: ClinicalTrials.gov NCT01344044.

Improving mental health care for people with an intellectual disability in Singapore: bridging the health-social care divide.

Intellectual disability is known to be associated with a high incidence of psychiatric co-morbidity and problem behaviours. However, there are many challenges in trying to meet the mental health needs of people with an intellectual disability, and these are often not adequately addressed in Singapore's current healthcare system. This article outlines the present service provisions for this area in the country and details the importance of, as well as difficulties in the integration of health and social care measures in service development and delivery.

Effectiveness of a brain-computer interface based programme for the treatment of ADHD: a pilot study.

Majority of children with attention deficit hyperactivity disorder (ADHD) have significant inattentive symptoms. We developed a progressive series of activities involving brain-computer interface-based games which could train users to improve their concentration. This pilot study investigated if the intervention could be utilized in children and if it could improve inattentive symptoms of ADHD. Ten medication-naive children aged 7 to 12 diagnosed with ADHD (combined or inattentive subtypes) received 20 sessions of therapy over a 10-week period. They were compared with age- and gendermatched controls. Both parent and teacher-rated inattentive score on the ADHD Rating Scale-IV improved more in the intervention group. A larger scale trial is warranted to further investigate the efficacy of our treatment programme in treating ADHD.

Sleep disturbances in Singaporean children with attention deficit hyperactivity disorder.

INTRODUCTION: Many studies have reported various levels of association between sleep disorders and attention deficit hyperactivity disorder (ADHD). This study aims to investigate sleep disturbances in children with ADHD prior to treatment and during treatment. MATERIALS AND METHODS: This study recruited 114 child and adolescent patients diagnosed with ADHD and 60 normal patients. Sleep disturbances are assessed using the parent-rated Child Behaviour Checklist (CBCL) questionnaire. In addition, chart reviews and semi-structured clinical interviews were conducted for 54 patients with ADHD who had been seen at the clinic since 2002 to examine the sleep disturbances they experienced during treatment over a 4-year period. RESULTS: Compared to the normal subjects, parents of children with ADHD reported that their children slept less. The summation score of the sleep items on the CBCL was also significantly higher in the ADHD group. Girls with ADHD also had more "trouble sleeping". When children with ADHD received treatment with medications, they experienced sleep-related side effects. Out of the 54 children with ADHD, 18.5% experienced sleep disturbance related to medication, with 13.0% reporting daytime somnolence and 5.5% reporting insomnia. CONCLUSION: Our study showed that there was an increased frequency of sleep disturbances in children with ADHD prior to treatment with medications. The children in our study appeared to sleep less. A significant proportion also experienced sleep disturbance during treatment with medication, of which daytime somnolence and insomnia were the most commonly reported problems. Future research in this area is needed to further examine the range of sleep disorders in ADHD children locally.