Training Executive, Attention, and Motor Skills (TEAMS): a Preliminary Randomized Clinical Trial of Preschool Youth with ADHD.

This preliminary randomized controlled trial compared Training Executive, Attention and Motor Skills (TEAMS), a played-based intervention for preschool children with attention-deficit/hyperactivity disorder (ADHD), to an active comparison intervention consisting of parent education and support (ClinicalTrials.gov Identifier: NCT01462032). The primary aims were to gauge preliminary efficacy and assist in further development of TEAMS. Four- and 5-year-old children with ADHD were randomly assigned to receive TEAMS (N = 26) or the comparison intervention (N = 26) with blinded assessments by parents, teachers and clinicians ascertained pretreatment, post-treatment, and 1- and 3-months post-treatment. Changes in ADHD severity, impairment, parenting factors, and neuropsychological functioning over time as a function of treatment condition were assessed using the PROC MIXED procedure in SAS. Across most measures, significant main effects for Time emerged; both treatments were associated with reduced ADHD symptoms that persisted for three months post-treatment. There were no significant Treatment effects or Time x Treatment interactions on symptom and impairment measures, suggesting that the magnitude of improvement did not differ between the two interventions. However, significant correlations emerged between the magnitude of behavioral change, as assessed by parents and clinicians, and the amount of time families engaged in TEAMS-related activities during treatment. Across a wide array of parenting and neuropsychological measures, there were few significant group differences over time. TEAMS and other psychosocial interventions appear to provide similar levels of benefit. Play-based interventions like TEAMS represent a potentially viable alternative/addition to current ADHD treatments, particularly for young children, but more research and further development of techniques are necessary.

Practitioner Review: Assessment and treatment of preschool children with attention-deficit/hyperactivity disorder.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) often emerges during the preschool years and remains impairing throughout the life span. Early identification and intervention may yield lasting benefits that alter the often-adverse trajectory of the disorder. METHODS: This Practitioner Review provides up-to-date information regarding the evaluation and treatment of ADHD in preschool children. The clinical presentation of ADHD in preschool children, its persistence into later childhood, the applicability of DSM-5 criteria for preschoolers with ADHD, and early predictors of long-term trajectories are addressed, as well as current findings from randomized controlled trials of both nonpharmacological and pharmacological interventions. RESULTS: Symptoms of hyperactivity/impulsivity extend down to age 3, but several inattention symptoms, as defined by DSM-V, less accurately differentiate preschoolers with and without ADHD. Most preschool youth with ADHD symptoms continue to manifest symptoms and impairment into school-age and adolescence. However, few predictors of persistence beyond early severity have been identified. Behavioral interventions constitute a first-line treatment for preschool ADHD symptoms, with telepsychiatry increasing in prominence to help to mitigate financial, geographic, and/or logistical barriers to care. Pharmacological interventions, particularly psychostimulants, also confer demonstrable benefits, yet efficacy and safety profiles are less desirable relative to findings in school-age youth. CONCLUSIONS: Acute treatments have demonstrable efficacy, but do not appear to fundamentally alter underlying mechanisms or long-term trajectories.

Low Working Memory rather than ADHD Symptoms Predicts Poor Academic Achievement in School-Aged Children.

This study examined whether working memory (WM), inattentive symptoms, and/or hyperactive/impulsive symptoms significantly contributed to academic, behavioral, and global functioning in 8-year-old children. One-hundred-sixty 8-year-old children (75.6% male), who were originally recruited as preschoolers, completed subtests from the Wechsler Intelligence Scale for Children-Fourth Edition, Integrated and Wechsler Individual Achievement Test-Second Edition to assess WM and academic achievement, respectively. Teachers rated children's academic and behavioral functioning using the Vanderbilt Rating Scale. Global functioning, as rated by clinicians, was assessed by the Children's Global Assessment Scale. Multiple linear regressions were completed to determine the extent to which WM (auditory-verbal and visual-spatial) and/or inattentive and hyperactive/impulsive symptom severity significantly contributed to academic, behavioral, and/or global functioning. Both auditory-verbal and visual-spatial WM but not ADHD symptom severity, significantly and independently contributed to measures of academic achievement (all p < 0.01). In contrast, both WM and inattention symptoms (p < 0.01), but not hyperactivity-impulsivity (p > 0.05) significantly contributed to teacher-ratings of academic functioning. Further, inattention and hyperactivity/impulsivity (p < 0.04), but not WM (p > 0.10) were significantly associated with teacher-ratings of behavioral functioning and clinician-ratings of global functioning. Taken together, it appears that WM in children may be uniquely related to academic skills, but not necessarily to overall behavioral functioning.

Impact of occupational, physical, and speech and language therapy in preschoolers with hyperactive/inattentive symptoms: A naturalistic 2-year follow-up study.

OBJECTIVE: Impact of speech and language therapy (ST) and occupational/physical therapy (OT/PT) on language and motor skills was examined in hyperactive/inattentive children. METHODS: Preschoolers were divided into those receiving and not receiving ST or OT/PT. RESULTS: Children receiving ST showed no gains in language functioning relative to those not receiving ST. OT/PT yielded similar results for motor functions. Hours of a service did not predict improvement. However, children who received ST showed improvement in social skills. DISCUSSION: The apparent lack of benefit suggests the need for further investigation into efficacy of these treatments in hyperactive/inattentive preschool children.

Early language mediates the relations between preschool inattention and school-age reading achievement.

OBJECTIVE: Early inattention is associated with later reading problems in children, but the mechanism by which this occurs is unclear. We investigated whether the negative relation between preschoolers' ADHD symptoms and 8-year-old reading achievement is directly related to the severity of inattention or is mediated by early language skills. METHOD: Children (n = 150; 76% boys) were evaluated at 3 time points: preschool (T1), mean (SD) age = 4.24 (.49) years; 1 year later (T2), mean (SD) age = 5.28 (.50) years; and during school age (T3), mean (SD) age = 8.61 (.31) years. At T1, parents' Kiddie-SADS responses were dimensionalized to reflect ADHD severity. Children completed the Language domain of the NEPSY (i.e., A Developmental Neuropsychological Assessment) at T1 and again at T2. At T3, children completed the Wechsler Individual Achievement Test, Second Edition Word Reading, Pseudoword Decoding, Reading Comprehension, and Spelling subtests, and their teachers completed ratings of Reading and Written Expression performance in school. The mediating effect of T2 Language on the relation between preschool Inattention and age 8 Reading was examined using the nonparametric bootstrapping procedure, while controlling for T1 Language. RESULTS: Language ability at T2 mediated the path from preschool inattention (but not hyperactivity/impulsivity) to 8-year-old reading achievement (both test scores and ratings) after controlling for preschoolers' language ability. CONCLUSIONS: Early attentional deficits may negatively impact school-age reading outcomes by compromising the development of language skills, which in turn imperils later reading achievement. Screening children with attentional problems for language impairment, as well as implementing early intervention for both attentional and language problems may be critical to promote reading achievement during school years. (PsycINFO Database Record

Good Holders, Bad Shufflers: An Examination of Working Memory Processes and Modalities in Children with and without Attention-Deficit/Hyperactivity Disorder.

The aim of this study was to examine working memory (WM) modalities (visual-spatial and auditory-verbal) and processes (maintenance and manipulation) in children with and without attention-deficit/hyperactivity disorder (ADHD). The sample consisted of 63 8-year-old children with ADHD and an age- and sex-matched non-ADHD comparison group (N=51). Auditory-verbal and visual-spatial WM were assessed using the Digit Span and Spatial Span subtests from the Wechsler Intelligence Scale for Children Integrated - Fourth Edition. WM maintenance and manipulation were assessed via forward and backward span indices, respectively. Data were analyzed using a 3-way Group (ADHD vs. non-ADHD)×Modality (Auditory-Verbal vs. Visual-Spatial)×Condition (Forward vs. Backward) Analysis of Variance (ANOVA). Secondary analyses examined differences between Combined and Predominantly Inattentive ADHD presentations. Significant Group×Condition (p=.02) and Group×Modality (p=.03) interactions indicated differentially poorer performance by those with ADHD on backward relative to forward and visual-spatial relative to auditory-verbal tasks, respectively. The 3-way interaction was not significant. Analyses targeting ADHD presentations yielded a significant Group×Condition interaction (p=.009) such that children with ADHD-Predominantly Inattentive Presentation performed differentially poorer on backward relative to forward tasks compared to the children with ADHD-Combined Presentation. Findings indicate a specific pattern of WM weaknesses (i.e., WM manipulation and visual-spatial tasks) for children with ADHD. Furthermore, differential patterns of WM performance were found for children with ADHD-Predominantly Inattentive versus Combined Presentations. (JINS, 2016, 22, 1-11).

Latent profile analysis of neuropsychological measures to determine preschoolers' risk for ADHD.

BACKGROUND: Hyperactive/Inattentive preschool children show clear evidence of neuropsychological dysfunction. We examined whether patterns and severity of test scores could reliably identify subgroups of preschoolers with differential risk for ADHD during school-age. METHOD: Typically developing (TD: n = 76) and Hyperactive/Inattentive (HI: n = 138) 3-4 year olds were assessed annually for 6 years (T1-T6). Latent profile analysis (LPA) was used to form subgroups among the HI group based on objective/neuropsychological measures (NEPSY, Actigraph and Continuous Performance Test). Logistic regression assessed the predictive validity of empirically formed subgroups at risk for ADHD diagnosis relative to the TD group and to each other from T2 to T6. RESULTS: Latent profile analysis yielded two subgroups of HI preschoolers: (a) selectively weak Attention/Executive functions, and (b) pervasive neuropsychological dysfunction across all measures. Both subgroups were more likely to have ADHD at all follow-up time-points relative to the TD group (OR range: 11.29-86.32), but there were no significant differences between the LPA-formed subgroups of HI children at any time-point. CONCLUSIONS: Objective/neuropsychological measures distinguish HI preschoolers from their TD peers, but patterns and severity of neuropsychological dysfunction do not predict risk for ADHD during school-age. We hypothesize that trajectories in at-risk children are influenced by subsequent environmental and neurodevelopmental factors, raising the possibility that they are amenable to early intervention.

Preliminary evidence for reduced posterror reaction time slowing in hyperactive/inattentive preschool children.

BACKGROUND: Attention deficit/hyperactivity disorder (ADHD) has been associated with deficits in self-regulatory cognitive processes, some of which are thought to lie at the heart of the disorder. Slowing of reaction times (RTs) for correct responses following errors made during decision tasks has been interpreted as an indication of intact self-regulatory functioning and has been shown to be attenuated in school-aged children with ADHD. This study attempted to examine whether ADHD symptoms are associated with an early-emerging deficit in posterror slowing. METHOD: A computerized two-choice RT task was administered to an ethnically diverse sample of preschool-aged children classified as either "control" (n = 120) or "hyperactive/inattentive" (HI; n = 148) using parent- and teacher-rated ADHD symptoms. Analyses were conducted to determine whether HI preschoolers exhibit a deficit in this self-regulatory ability. RESULTS: HI children exhibited reduced posterror slowing relative to controls on the trials selected for analysis. Supplementary analyses indicated that this may have been due to a reduced proportion of trials following errors on which HI children slowed rather than due to a reduction in the absolute magnitude of slowing on all trials following errors. CONCLUSIONS: High levels of ADHD symptoms in preschoolers may be associated with a deficit in error processing as indicated by posterror slowing. The results of supplementary analyses suggest that this deficit is perhaps more a result of failures to perceive errors than of difficulties with executive control.

Reliable ratings or reading tea leaves: can parent, teacher, and clinician behavioral ratings of preschoolers predict ADHD at age six?

To assess the relative ability of parent, teacher, and clinician behavioral ratings of preschoolers to predict ADHD severity and diagnosis at 6 years of age. Hyperactive/inattentive preschoolers [N = 104, 75 % boys, Mean (SD) age = 4.37 (0.47) years] were followed over 2 years (mean = 26.44 months, SD = 5.66). At baseline (BL), parents and teachers completed the ADHD-RS-IV and clinicians completed the Behavioral Rating Inventory for Children following a psychological testing session. At age 6, [Mean (SD) age = 6.62 (0.35) years], parents were interviewed with the K-SADS-PL; teachers completed the ADHD-RS-IV; and laboratory measures of hyperactivity, impulsivity, and inattention were obtained from children. Hierarchical logistic and linear regression analyses examined which combination of BL ratings best predicted 6-year-old ADHD diagnosis and severity, respectively. At age 6, 56 (53.8 %) children met DSM-IV criteria for a diagnosis of ADHD. BL ratings from parent/teacher/clinician, parent/teacher and parent/clinician combinations significantly predicted children who had an ADHD diagnosis at age 6. Parent and clinician, but not teacher, behavior ratings were significant independent predictors of ADHD diagnosis and severity at 6-years-old. However, only clinician reports of preschoolers' behaviors predicted laboratory measures of over-activity and inattention at follow-up. Cross-situationality is important for a diagnosis of ADHD during the preschool years. Among parents, teachers and clinicians, positive endorsements from all three informants, parent/teacher or parent/clinician appear to have prognostic value. Clinicians' ratings of preschoolers' inattention, impulsivity and hyperactivity are valid sources of information for predicting ADHD diagnosis and severity over time.

Neuropsychological functioning and severity of ADHD in early childhood: a four-year cross-lagged study.

Children with attention deficit/hyperactivity disorder (ADHD) have poorer neuropsychological functioning relative to their typically developing peers. However, it is unclear whether early neuropsychological functioning predicts later ADHD severity and/or the latter is longitudinally associated with subsequent neuropsychological functioning; and whether these relations are different in children with and without early symptoms of ADHD. This study aimed to examine the longitudinal associations between ADHD severity and neuropsychological functioning among children at high and low risk of developing ADHD. Hyperactive/Inattentive (H/I; n = 140) and Typically developing (TD; n = 76) preschoolers (age 3-4 years) were recruited (BL) and followed annually for 3 years (F1, F2, and F3). Teachers rated the children's ADHD severity and impairment using the Behavior Assessment System for Children-2 and the Children's Problem Checklist, respectively. Parent reports of children's ADHD severity were obtained using the Kiddie-Schedule for Affective Disorders and Schizophrenia - Present and Lifetime version. Neuropsychological functioning was assessed using the NEPSY. In the full sample, there were bidirectional longitudinal associations between neuropsychological functioning and ADHD severity between F1 and F3. Among H/I children, neuropsychological functioning at F1 and F2 predicted ADHD severity at F2 and F3, respectively. In contrast, among TD children the only significant relationship observed was that elevated ADHD symptoms at F2 were associated with poorer neuropsychological functioning at F3. Improved neuropsychological functioning may attenuate ADHD symptoms and associated impairment among H/I children during the early school years. Interventions designed to improve neuropsychological functioning among young H/I children may be beneficial in reducing their ADHD severity.

Association between variation in neuropsychological development and trajectory of ADHD severity in early childhood.

OBJECTIVE: This longitudinal study examined if changes in neuropsychological functioning were associated with the trajectory of symptoms related to attention deficit hyperactivity disorder (ADHD) and impairment between preschool and school age. METHOD: The sample consisted of 3- and 4-year-old children (N=138) who were identified as being at risk for ADHD based on parent and teacher reports. Neuropsychological functioning was measured annually using the NEPSY at four time points (mean ages, 4.19, 5.36, 6.35, and 7.35 years). ADHD symptoms and impairment were assessed with semiannual parent and teacher reports using the ADHD Rating Scale-IV and the Children's Problems Checklist at 10 time points (mean ages at baseline and final assessment, 4.19 and 8.81 years, respectively). Hierarchical linear modeling was used to assess the trajectories of change in neuropsychological functioning and ADHD severity as well as the association of change in neuropsychological functioning with change in ADHD severity over time. RESULTS: Baseline neuropsychological functioning was not significantly associated with the slope of change in ADHD severity. However, the magnitude of change in neuropsychological functioning was linearly associated with the trajectory of ADHD symptom severity and impairment, such that individuals with greater neuropsychological growth over time had a greater diminution of ADHD severity and impairment. Family socioeconomic status at baseline was significantly associated with initial ADHD severity and impairment, but not with change over time. CONCLUSIONS: Interventions that enhance neuropsychological functioning at an early age may be beneficial in attenuating long-term ADHD severity and impairment.

Training executive, attention, and motor skills: a proof-of-concept study in preschool children With ADHD.

OBJECTIVE: To examine whether cognitive enhancement can be delivered through play to preschoolers with ADHD and whether it would affect severity of ADHD symptoms. METHOD: Twenty-nine 4- and 5-year-old children and their parents participated in separate group sessions (3-5 children/group). Child groups were introduced games designed to enhance inhibitory control, working memory, attention, visuospatial abilities, planning, and motor skills. Parent groups were encouraged playing these games with their children at least 30 to 45 min/day and taught strategies for scaffolding difficulty levels and dealing with obstacles to daily playing. RESULTS: Parent ratings and session attendance indicated considerable satisfaction with the program. Parent (p < .001) and teacher (p = .003) ratings on the ADHD-Rating Scale-IV (ADHD-RS-IV) indicated significant improvement in ADHD severity from pre- to post-treatment, which persisted 3 months later. CONCLUSION: This play-based intervention for preschoolers with ADHD is readily implemented at home. Preliminary evidence suggests efficacy beyond the termination of active treatment.

ADHD Preschoolers with and without ODD: do they act differently depending on degree of task engagement/reward?

OBJECTIVE: To examine the impact of reinforcement on reaction time (RT) and RT variability (RT standard deviation [RTSD]) in preschoolers with ADHD with and without oppositional defiant disorder (ODD), and a typically developing (TD) comparison group. METHOD: Participants were administered a computerized task consisting of two conditions: simple RT (SRT) and reinforced SRT (SRTr). Data were analyzed using two-way (Group × Condition) mixed ANOVAs and followed-up using pairwise comparisons. RESULTS: RTs were significantly shorter and less variable during the SRTr than the SRT condition. A significant Group x Condition interaction was observed for RTSD (F= 3.38, p < .05); post hoc analyses indicated that the RTSD of the ADHD + ODD group was significantly more variable than that of the TD group during the SRT condition (F = 4.81, p < .05). However, their RTSD was statistically indistinguishable from the other groups during the SRTr condition. CONCLUSION: Preschoolers who are oppositional/defiant and hyperactive are the most responsive to feedback/reward.

Exposure to gestational diabetes mellitus and low socioeconomic status: effects on neurocognitive development and risk of attention-deficit/hyperactivity disorder in offspring.

OBJECTIVE: To examine the independent and synergistic effects of gestational diabetes mellitus (GDM) and low socioeconomic status (SES) on neurodevelopment and attention-deficit/hyperactivity disorder (ADHD) outcomes. DESIGN: Cohort study. SETTING: Flushing, New York. PARTICIPANTS: A total of 212 preschool children as a part of the ongoing cohort study. MAIN EXPOSURES: Gestational diabetes mellitus and low SES. MAIN OUTCOME MEASURES: Primary outcomes are ADHD diagnosis based on Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria at age 6 years and several well-validated measures of neurobehavioral outcomes, cognitive functioning, ADHD symptoms, and temperament at age 4 years. Secondary outcomes are parent and teacher reports of behavioral and emotional problems at age 6 years. Neurobehavioral measures in relation to GDM and low SES were examined using generalized estimating equations and multivariate logistic regression analyses. RESULTS: Both maternal GDM and low SES were associated with an approximately 2-fold increased risk for ADHD at age 6 years. However, the risk by GDM was greater among lower SES families than among higher SES families. Children exposed to both GDM and low SES demonstrated compromised neurobehavioral functioning, including lower IQ, poorer language, and impoverished behavioral and emotional functioning. A test of additive interaction found that the risk for ADHD increased over 14-fold (P = .006) when children were exposed to both GDM and low SES. Neither children exposed to maternal GDM alone nor those exposed to low SES alone had a notable increased risk for ADHD. CONCLUSIONS: Maternal GDM and low SES, especially in combination, heighten the risk for childhood ADHD. Long-term prevention efforts should be directed at mothers with GDM to avoid suboptimal neurobehavioral development and mitigate the risk for ADHD among their offspring.

Diagnosis of ADHD in adults: what is the appropriate DSM-5 symptom threshold for hyperactivity-impulsivity?

OBJECTIVE: To empirically identify the appropriate symptom threshold for hyperactivity-impulsivity for diagnosis of ADHD in adults. METHOD: Participants were 88 adults (M [SD] age = 41.69 [11.78] years, 66% female, 16% minority) meeting formal DSM-IV criteria for ADHD combined or predominantly inattentive subtypes based on a structured diagnostic interview keyed to DSM-IV (Conners' Adult ADHD Diagnostic Interview for DSM-IV [CAADID]). All participants also completed the Conners' Adult ADHD Rating Scale (CAARS), which was normed on the general adult population and includes subscales for DSM-IV inattentive and DSM-IV hyperactive-impulsive symptoms. A T-score threshold of 65 (at least 1.5 SD above population mean) on the CAARS DSM-IV hyperactive-impulsive dimension was used to identify participants with empirically elevated symptom severity. RESULTS: Of 88 participating adults, 48 (55%) had a T-score of at least 65 (1.5 SD) on the CAARS DSM-IV Hyperactive-Impulsive scale. Of these, only 25 (52%) met the DSM-IV cutoff of six hyperactive-impulsive symptoms on the CAADID. Thus, approximately half of those who reported empirically elevated hyperactive-impulsive complaints on the CAARS did not concurrently meet the six-symptom DSM-IV cutoff on the CAADID. An alternative cutoff of four hyperactive-impulsive symptoms on the CAADID captured 39 (81%) cases identified by the CAARS. CONCLUSION: In adults, mandating at least six hyperactive-impulsive symptoms excludes a significant percentage (almost half) of adults who are at least 1.5 SD above the population mean on a dimensional measure of hyperactivity-impulsivity. These data provide a compelling basis for lowering the symptom threshold of hyperactivity-impulsivity for adults in the DSM-5.

Examining the interplay among negative emotionality, cognitive functioning, and attention deficit/hyperactivity disorder symptom severity.

Cognition and emotion, traditionally thought of as largely distinct, have recently begun to be conceptualized as dynamically linked processes that interact to influence functioning. This study investigated the moderating effects of cognitive functioning on the relationship between negative emotionality and attention deficit/hyperactivity disorder (ADHD) symptom severity. A total of 216 (140 hyperactive/inattentive; 76 typically developing) preschoolers aged 3-4 years were administered a neuropsychological test battery (i.e., NEPSY). To avoid method bias, child negative emotionality was rated by teachers (Temperament Assessment Battery for Children-Revised), and parents rated symptom severity on the ADHD Rating Scale (ADHD-RS-IV). Hierarchical Linear Regression analyses revealed that both negative emotionality and Perceptual-Motor & Executive Functions accounted for significant unique variance in ADHD symptom severity. Significant interactions indicated that when negative emotionality is low, but not high, neuropsychological functioning accounts for significant variability in ADHD symptoms, with lower functioning predicting more symptoms. Emotional and neuropsychological functioning, both individually and in combination, play a significant role in the expression of ADHD symptom severity.

Childhood stimulant treatment and teen depression: is there a relationship?

Recent preclinical data have raised the possibility that prepubertal treatment of attention-deficit/hyperactivity disorder (ADHD) with stimulant medication might increase risk for later depression. The current longitudinal study investigated whether children with ADHD who were treated with stimulant medication displayed heightened levels of adolescent depression. Adolescents diagnosed with ADHD during childhood who had received a minimum of 1 year of treatment with stimulant medication were compared to adolescents with a childhood history of ADHD who were never treated with stimulants and a demographically matched comparison group on self-reports of depressive symptoms and diagnoses of depressive disorders. Both subgroups with childhood ADHD reported significantly higher dimensional ratings of depression and categorical rates of depressive disorders relative to the comparison group (all p<0.05), yet those who were and were not medicated did not differ from one another. Results indicate that, while childhood ADHD increases risk for adolescent depression, stimulant treatment for ADHD neither heightens nor protects against such risk.

Prenatal exposure to maternal and paternal smoking on attention deficit hyperactivity disorders symptoms and diagnosis in offspring.

The study examined the effect of maternal and paternal smoking during pregnancy on the child's inattention and hyperactivity/impulsivity symptoms, and the risk for attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). Generalized estimating equations, incorporating data from multiple informants (parents and teachers), was used to evaluate levels of ADHD as a function of parental smoking. The risk for ADHD, ODD, and comorbid ADHD and ODD was evaluated using polytomous logistic regression. We found that maternal, but not paternal, smoking was significantly associated with elevated inattention, hyperactivity/impulsivity, and total ADHD symptoms in children. Children of smoking, relative to nonsmoking, mothers had a significant increased risk for comorbid ADHD and ODD and ADHD, but not ODD. Although father's smoking was not associated with an increased risk, as it strongly influenced mothers' smoking, intervention for both parents may be most effective in preventing the pathway to ADHD-related problems in the children.

Efficacy of meta-cognitive therapy for adult ADHD.

OBJECTIVE: The authors investigated the efficacy of a 12-week manualized meta-cognitive therapy group intervention designed to enhance time management, organization, and planning in adults with attention deficit hyperactivity disorder (ADHD). METHOD: Eighty-eight clinically referred adults who met DSM-IV criteria for ADHD according to clinical and structured diagnostic interviews and standardized questionnaires were stratified by ADHD medication use and otherwise randomly assigned to receive meta-cognitive therapy or supportive psychotherapy in a group modality. Meta-cognitive therapy uses cognitive-behavioral principles and methods to impart skills and strategies in time management, organization, and planning and to target depressogenic and anxiogenic cognitions that undermine effective self-management. The supportive therapy condition controlled for nonspecific aspects of treatment by providing support while avoiding discussion of cognitive-behavioral strategies. Therapeutic response was assessed by an independent (blind) evaluator via structured interview before and after treatment as well as by self-report and collateral informant behavioral ratings. RESULTS: General linear models comparing change from baseline between treatments revealed statistically significant effects for self-report, collateral report, and independent evaluator ratings of DSM-IV inattention symptoms. In dichotomous indices of therapeutic response, a significantly greater proportion of members of the meta-cognitive therapy group demonstrated improvement compared with members of the supportive therapy group. Logistic regression examining group differences in operationally defined response (controlling for baseline ADHD severity) revealed a robust effect of treatment group (odds ratio=5.41; 95% CI=1.77-16.55). CONCLUSIONS: Meta-cognitive therapy yielded significantly greater improvements in dimensional and categorical estimates of severity of ADHD symptoms compared with supportive therapy. These findings support the efficacy of meta-cognitive therapy as a viable psychosocial intervention.

Profiles of service utilization and the resultant economic impact in preschoolers with attention deficit/hyperactivity disorder.

OBJECTIVE: To examine whether preschool children with Attention deficit/hyperactivity disorder (ADHD) utilize more speech and language therapy (ST), occupational therapy (OT), and physical therapy (PT) services and are more likely to be placed in special education (SPED) classrooms as compared to their peers. Corresponding financial consequences were also examined. METHODS: The amount of ST, OT, and PT, as well as SPED placements, was examined in 3- and 4-year-old children with and without ADHD (n = 109 and n = 97, respectively) during the baseline portion of an ongoing, 5-year longitudinal study. Costs for individual services and aggregate cost were determined per child and compared across groups. RESULTS: Preschool children with ADHD were more likely to receive individual and multiple services. Higher rates of service utilization translated into increased costs for each individual service with the exception of PT. CONCLUSIONS: A comprehensive understanding of service utilization in the early years of development is important in addressing the increased service use in the preschool years and assist in guiding allocation of resources.