Fergusson DM, Boden JM. University of Otago, Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand.

Drug Alcohol Depend. 2008 Jan 31

BACKGROUND: The present study examined the associations between cannabis use in adolescence and young adulthood and self-reported adult attention deficit/hyperactivity disorder (ADHD) symptoms in adulthood.

METHODS: A 25-year prospective longitudinal study of the health, development, and adjustment of a birth cohort of 1265 New Zealand children.
Measures included assessments of adolescent and young adult cannabis use and ADHD symptoms at age 25, measures of childhood socioeconomic disadvantage,
family adversity, childhood and early adolescent behavioural adjustment and cognitive ability, and adolescent and young adult other drug use.

RESULTS: Cannabis use by age 25 was significantly (p<.0001) associated with increasing self-reported adult ADHD symptoms at age 25. Adjustment of the
association for potentially confounding factors from childhood and early adolescence reduced the magnitude of the association, but it remained statistically significant (p<.0001). However, control for the mediating effects of other drug use in adolescence and early adulthood reduced the association between cannabis use and adult ADHD symptoms to statistical non-significance (p>.20).

CONCLUSIONS: The current study suggested that the association between cannabis use and adult ADHD symptoms was mediated by other substance use
that was associated with cannabis use. The results suggest that cannabis use leads to other drug use, which in turn leads to increased ADHD symptoms.
However, it should be noted that the potential influence of such factors as genetic predispositions may still be unaccounted for

2. Improving School Outcomes for Students with ADHD: Using the Right Strategies in the Context of the Right Relationships

J Atten Disord 2008; 11; 519 George DuPaul and Thomas J. Power

Children and adolescents with ADHD invariably experience school difficulties. In fact, school performance deficits should be expected given that DSM–IV–TR criteria require an individual to exhibit academic and/or social impairment across more than one setting (American Psychiatric Association, 2000). The primary problems that students with ADHD experience in school settings include academic underachievement, aberrant interpersonal relationships with teachers and/or peers, and difficulties controlling behavior, particularly during instructional or work periods (Barkley, 2006; DuPaul & Stoner, 2003). As a result, treatment typically is directed at enhancing behavioral, social, and academic functioning.

Our premise is that to date, research has almost exclusively emphasized the development of effective strategies to modify symptomatic behaviors and, in some cases, associated academic and social impairment. Yet, we argue that it is equally important to focus treatment on the development of partnerships with families and school professionals and to facilitate collaborative relationships between the family and school systems. Stated differently, the key to school success for students with ADHD is the implementation of the right strategies in the context of the right relationships.

The school functioning of students with ADHD typically has been assessed using norm-referenced achievement tests and teacher behavior ratings (e.g., MTA Cooperative Group, 1999, 2004). Although these measures are reliable and valid indicators of school performance, they do not provide a comprehensive picture of how students with ADHD are functioning in the educational environment. Thus it is important for research on school outcomes to include direct observations of classroom behavior, criterion-referenced academic indicators (e.g., curriculum-based measurement and goal attainment scaling), teacher ratings of academic skills and enablers (e.g., Academic Competence Evaluation Scale; DiPerna & Elliott, 2000), products of academic behavior (i.e., classwork and homework), and so-called real-world indicators (e.g., report card grades and office disciplinary referrals). To collect comprehensive data about school functioning, relationships must be built with and between teachers, parents, and school administrators.

Given the myriad of difficulties that students with ADHD typically experience in school settings, interventions must target academic, behavioral, and interpersonal
outcomes using empirically supported strategies. The most common and widely researched treatments for ADHD include psychostimulant medication (e.g., methylphenidate) and behavior modification strategies (Barkley, 2006; MTA Cooperative Group, 1999, 2004).

Although academic interventions for students with ADHD have not been as widely studied as behavioral treatments, investigations have provided support for academic remediation strategies, including computer-assisted instruction (e.g., Clarfield & Stoner, 2005), classwide peer tutoring (DuPaul, Ervin, Hook, & McGoey, 1998), homebased parent tutoring (Hook & DuPaul, 1999) or homework support (Power, Karustis, & Habboushe, 2001), self-regulated strategy for written expression (Reid & Lienemann, 2006), and directed note-taking (Evans, Pelham, & Grudberg, 1995). Another viable treatment approach for enhancing the school functioning of students with ADHD is the use of home–school communication programs (e.g., daily report card).

The efficacy of the daily report card strategy has been supported particularly for students with ADHD of mild to moderate severity, most notably in the research of Pelham and colleagues (e.g., Pelham et al., 1993). Although medication, behavioral interventions, and academic strategies are effective in reducing ADHD symptoms and enhancing school functioning, strategy development alone is rarely sufficient for several reasons. First, adherence with prescribed treatment can be very inconsistent even for simple medication regimens. Adherence, which is presumed to influence outcome, is impacted by many factors, including regimen complexity, level of participant involvement in treatment planning, and quality of intervention integrity feedback provided to whomever delivers the treatment (e.g., DiGennaro, Martens, & Kleinmann, 2007; Kelleher, Riley-Tillman, & Power, in press). Importantly, treatment adherence also may be a function of parental stress and quality of interactions in the home environment (Gau et al., 2006).

Second, a comprehensive treatment plan for students with ADHD requires extensive school–home collaboration and communication that often is difficult to achieve. Finally, there often is a gap between treatment strategies that are efficacious under controlled research conditions and interventions that are feasible to implement in the everyday context of home and school settings. Children with ADHD vary dramatically in their responsiveness to intervention (Jensen et al., 2007). Responsiveness to psychosocial interventions for ADHD is related to numerous factors, including characteristics of the child (e.g., severity of comorbid internalizing problems; MTA Cooperative Group, 1999) and qualities of the environment (e.g., socioeconomic status [SES] of families, ADHD status of parents; Jensen et al., 2007; Rieppi et al., 2002). Despite the pioneering work of Wahler and colleagues (e.g.,Wahler & Dumas, 1989), very little is known about how characteristics of the family influence treatment outcomes.

However, it is reasonable to hypothesize that family engagement in intervention is a critical intervening variable. Family engagement refers to the extent to which families are actively involved in intervention. Although level of engagement typically is operationalized by indicators of dosage (e.g., attendance rates and number of hours in treatment), this construct also refers to the extent to which families are actively involved in treatment sessions and follow through by implementing intervention strategies between sessions. Family factors (e.g., parental psychopathology and SES) clearly influence degree of family engagement in treatment, but there also is evidence that clinician factors can impact family involvement. For example, a clinician’s ability to apply motivational interviewing strategies, including empathic understanding and affirmation of family efforts to change, has been shown repeatedly to influence engagement in treatment (Miller & Rollnick, 2002).

Research related to motivational interviewing has demonstrated the importance of clinician–family partnerships in promoting engagement in treatment and, ultimately, positive outcomes. The construct of intervention engagement also can be applied to the school and family–school partnership, although there is little research in this area. Virtually every clinician who has consulted in schools realizes that there is extraordinary variability in the extent to which teachers buy in to treatment and consistently implement intervention plans in the classroom. Also, variability in the quality of family–school partnerships is striking. Improving teacher buy-in is a complicated process, but one factor that seems critical is engaging teachers in a full partnership to identify target behaviors, plan strategies and methods of implementation, and evaluate outcomes. This type of partnership process has been demonstrated to be more effective in improving strategy implementation than traditional, expert-driven methods of consultation (Kelleher et al., in press).

To change participant engagement in intervention, it is essential that we find ways to assess it. Given the illusiveness of the engagement construct, multiple methods will be needed, including multi-informant reports and direct observations of engagement. Also, analyzing permanent products of intervention (e.g., treatment diaries kept by parents, daily home–school notes, and records of home–school communication kept by teachers) may provide a relatively objective method of assessing degree of engagement. To be successful interventionists, it is essential that we use interventions that are empirically supported (i.e. the right strategies). However, research and practice have clearly taught us that it is not sufficient to use the most appropriate techniques in treatment.

It is equally important that participants in intervention (i.e., families and school professionals) are highly engaged in the process of designing, implementing, and evaluating the strategies. A critical responsibility for the clinician, therefore, is to promote partnerships with families and school professionals as well as between these individuals so that system dynamics (i.e., the right relationships) are in place for meaningful change to occur. Psychosocial intervention research related to children with ADHD historically has focused almost exclusively on the strategies of intervention. It is time for researchers to shift their focus to relationships and to develop an integrated approach that promotes the right strategies with the right relationships.

3. Atomoxetine and Osmotically Released Methylphenidate for the Treatment of Attention Deficit Hyperactivity Disorder: Acute Comparison and Differential Response

Jeffrey H. Newcorn, M.D., Christopher J. Kratochvil, M.D., Albert J. Allen, M.D., Ph.D., Charles D. Casat, M.D., Dustin D. Ruff, Ph.D., Rodney J. Moore, Ph.D., David Michelson, M.D.

Am J Psychiatry Published February 15, 2008

OBJECTIVE: Response to atomoxetine, a nonstimulant norepinephrine-specific reuptake inhibitor, was compared with the effect of osmotic-release oral methylphenidate, a long-acting methylphenidate preparation, in patients with attention deficit hyperactivity disorder (ADHD).

METHOD: In a large placebo-controlled, double-blind study, patients ages 6–16 with ADHD, any subtype, were randomly assigned to receive 0.8–1.8 mg/kg per day of atomoxetine (N=222), 18–54 mg/day of osmotically released methylphenidate (N=220), or placebo (N=74) for 6 weeks. The a priori specified primary analysis compared response (at least 40% decrease in ADHD Rating Scale total score) to osmotically released methylphenidate with response to atomoxetine and placebo. After 6 weeks, patients treated with methylphenidate were switched to atomoxetine under double-blind conditions.

RESULTS: The response rates for both atomoxetine (45%) and methylphenidate (56%) were markedly superior to that for placebo (24%), but the response to osmotically released methylphenidate was superior to that for atomoxetine. Each medication was well tolerated, with completion rates and discontinuations for adverse events not significantly different from those for placebo. Of the 70 subjects who did not respond to methylphenidate, 30 (43%) subsequently responded to atomoxetine. Likewise, 29 (42%) of the 69 patients who did not respond to atomoxetine had previously responded to osmotically released methylphenidate.

CONCLUSIONS: Response was significantly greater with osmotically released methylphenidate than with atomoxetine. One-third of patients who received methylphenidate followed by atomoxetine responded better to one or the other, suggesting that there may be preferential responders.

4. Reciprocal Relationships between Parenting Behavior and Disruptive Psychopathology from Childhood through Adolescence.

Burke JD, Pardini DA, Loeber R. Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh, 3811 O'Hara St., Pittsburgh, PA, 15213, USA, J Abnorm Child Psychol. 2008 Feb 20

Theoretical models suggest that child behaviors influence parenting behaviors, and specifically that unpleasant child behaviors coerce parents to discontinue engaging in appropriate discipline. This study examined reciprocal relationships between parenting behaviors (supervision, communication, involvement, timid discipline and harsh punishment) and child disruptive disorder symptoms (ADHD, ODD and CD) in a clinic referred sample of 177 boys.

Annual measures, including structured clinical interviews, were obtained from the beginning of the study (when boys were between the ages of 7 to 12) to age 17. Specific reciprocal influence was observed; only timid discipline predicted worsening behavior, namely ODD symptoms, and ODD symptoms predicted increases in timid discipline. Greater influence from child behaviors to parenting practices was found: ODD also predicted poorer communication and decreased involvement, and CD redicted poorer supervision. ADHD was neither predictive of, nor predicted by, parenting behaviors. The results are specifically supportive of a coercive process between child behaviors and parenting behaviors, and generally suggestive of greater influence of child behaviors on parenting behaviors than of parenting behaviors on child behaviors.