Reducing disparities in behavioral health treatment in pediatric primary care: a randomized controlled trial comparing Partnering to Achieve School Success (PASS) to usual ADHD care for children ages 5 to 11 - study protocol.

BACKGROUND: Integrating behavioral health services into pediatric primary care can improve access to care, especially for children marginalized by poverty and racial/ethnic minority status. In primary care, a common presenting concern is attention-deficit/hyperactivity disorder (ADHD). Services in primary care for marginalized children with ADHD typically include medication alone; therapy to improve skills and build relationships is less available. This study evaluates the effectiveness of a behavioral intervention offered through primary care for marginalized families coping with ADHD (Partnering to Achieve School Success, PASS) compared to treatment as usual (TAU). METHOD: Three hundred participants will be randomly assigned to PASS or TAU. Participants include children ages 5 to 11 who have ADHD and are from economically marginalized families. PASS is a personalized, enhanced behavioral intervention that includes evidence-based behavior therapy strategies and enhancements to promote family engagement, increase caregiver distress tolerance, and provide team-based care to improve academic and behavioral functioning. TAU includes services offered by primary care providers and referral for integrated behavioral health or community mental health services. Outcomes will be assessed at mid-treatment (8 weeks after baseline), post-treatment (16 weeks), and follow-up (32 weeks) using parent- and teacher-report measures of service use, child academic, behavioral, and social functioning, parenting practices, family empowerment, and team-based care. Mixed effects models will examine between-group differences at post-treatment and follow-up. Analyses will examine the mediating role of parenting practices, family empowerment, and team-based care. Subgroup analyses will examine differential effects of intervention by child clinical characteristics and socioeconomic factors. DISCUSSION: This study is unique in targeting a population of children with ADHD marginalized by low socioeconomic resources and examining an intervention designed to address the challenges of families coping with chronic stress related to poverty. TRIAL REGISTRATION: This study was registered on clinicaltrials.gov (NCT04082234) on September 5, 2019, prior to enrollment of the first participant. The current version of the protocol and IRB approval date is October 4, 2023. Results will be submitted to ClinicalTrials.gov no later than 30 days prior to the due date for the submission of the draft of the final research report to the Patient-Centered Outcomes Research Institute.

Sluggish cognitive tempo and processing speed in adolescents with ADHD: do findings vary based on informant and task?

Few studies have examined whether behavioral sluggish cognitive tempo (SCT) symptoms are related to speeded task performance. Mixed findings in existing research could be due to previous studies using a broad conceptualization of processing speed, not including self-report of SCT symptoms, and relying on non-optimal measures of SCT. Using a multi-informant design with both parent- and adolescent-reported SCT symptoms, the present study provides a preliminary test of the hypothesis that SCT symptoms would be associated with slower performance on tasks having greater graphomotor and fine motor demands. Participants were 80 adolescents (ages 13-17 years; 71% male) with attention-deficit/hyperactivity disorder (ADHD). Adolescents and parents completed ratings of SCT. Adolescents were administered the Wechsler Symbol Search and Coding subtests and the Grooved Pegboard Test. When adjusting for age, sex, and ADHD symptom severity, parent-reported SCT symptoms were not significantly associated with Symbol Search or Coding scores but were significantly associated with slower Grooved Pegboard time. Adolescent-reported SCT symptoms were not significantly associated with Symbol Search but were significantly associated with lower Coding scores and slower Grooved Pegboard time. Findings provide preliminary support for the hypothesis that SCT may be more clearly associated with processing speed task performance as motor demands increase and provide a potential explanation for the mixed literature on SCT in relation to processing speed by demonstrating that the presence and magnitude of associations vary by informant and task.

The Revised Child Anxiety and Depression Scales (RCADS): Psychometric Evaluation in Children Evaluated for ADHD.

Co-occurring internalizing symptoms are common and important to assess in children with attention-deficit/hyperactivity disorder (ADHD). One frequently used child self-report measure of internalizing symptoms is the Revised Child Anxiety and Depression Scales (RCADS), yet the psychometric properties of the RCADS remain unexamined in children referred for ADHD specifically. The present study evaluated the RCADS in 117 children (ages 8-12; 66% male) evaluated for suspected ADHD at an ADHD specialty clinic (83% met criteria for ADHD). In addition to the RCADS, children completed measures of social anxiety and depression. Parents completed the RCADS-Parent Version (RCADS-P) in addition to other measures of internalizing and externalizing symptoms. Children and parents both completed a measure of aggression. Factor structure, reliability, and convergent/discriminant validity of the RCADS were examined. Results supported the six-factor structure of the child-report RCADS (Separation Anxiety, Social Phobia, Generalized Anxiety Disorder, Panic Disorder, and Obsessive Compulsive Disorder, Major Depressive Disorder). The RCADS demonstrated adequate reliability as well as convergent and discriminant validity with other child ratings. The total anxiety score on the RCADS also demonstrated convergent and discriminant validity with parent measures, though the depression score on the RCADS did not. Findings provide preliminary psychometric support for the RCADS in children referred for ADHD.

Suicidal Behaviors in College Students: Frequency, Sex Differences, and Mental Health Correlates Including Sluggish Cognitive Tempo.

PURPOSE: To (1) describe rates of suicidal behaviors in a sample of college students, (2) evaluate sex differences, and (3) provide a preliminary examination of the unique association of sluggish cognitive tempo (SCT) symptoms and other mental health dimensions in relation to suicidal behaviors in college students. METHODS: Participants were 1,704 college students from two universities who completed measures assessing mental health symptoms and suicidal behaviors (i.e., past ideation/attempts, past-year ideation, disclosure of intent to commit suicide to another person, and likelihood of a future suicide attempt). RESULTS: Four percent of participants reported a previous suicide attempt and 2.2% indicated that it was likely they would attempt suicide someday. 7.5% reported thinking about killing themselves often in the past year; 41.4% of these participants reported they had never told someone they might attempt suicide. Approximately one quarter (24%) of participants were classified with suicide risk based on an empirically established cutoff score, though rates differed between women (26.1%) and men (20.4%). Women were also more likely than men to report a previous suicide attempt and to tell someone else about their suicidal ideation. In regression models, depression was the strongest correlate of suicidal behaviors. Attention-deficit/hyperactivity disorder symptoms were unassociated with suicidal behaviors when accounting for internalizing symptoms. SCT remained significantly associated with increased suicidal behaviors beyond other mental health dimensions including depression. CONCLUSIONS: A substantial minority of college students report suicidal behaviors, with sex differences dependent on the specific behavior examined. This study provides the first evidence linking SCT to suicidal behaviors in young adults.

Children's sleep problems are associated with poorer student-teacher relationship quality.

OBJECTIVE: Children's sleep problems are associated with poorer student functioning in the school environment, including impairment in peer relationships; yet, no studies have examined sleep functioning in relation to the student-teacher relationship. The objective of this study was to examine whether child-rated total sleep problems or specific sleep problem domains (bedtime problems, nighttime problems, or daytime sleepiness) were associated with teacher-rated student-teacher closeness and conflict after controlling for student mental health symptoms known to be associated with both greater sleep problems and poorer student-teacher relationship quality. The study also examined whether age moderated the relation between sleep problems and student-teacher relationship quality. PARTICIPANTS: Participants were 175 children (81 boys and 94 girls) in the first to sixth grades (age = 6-13 years) and their teachers. METHODS: Children completed the Sleep Self-Report. Teachers completed a measure of student mental health symptoms (ie, attention-deficit/hyperactivity disorder, oppositional defiant disorder, conduct disorder, and anxiety/depression) and a measure of their relational closeness and conflict with each student. RESULTS: Total sleep problems were associated with greater student-teacher conflict, after controlling for child mental health symptoms and demographic factors. This association was moderated by age such that sleep problems were associated with conflict for younger children but not older children. Notably, daytime sleepiness specifically was associated with less student-teacher closeness. CONCLUSIONS: This is the first study to demonstrate a relation between student sleep functioning and the student-teacher relationship. Results of the study suggest that sleep may be an important component of school-based screening and evaluation efforts, as sleep is an important malleable factor related to school success.

Rumination in relation to suicide risk, ideation, and attempts: Exacerbation by poor sleep quality?

BACKGROUND: Rumination, particularly brooding rumination, is associated with suicide risk, ideation and attempts; however, findings are inconsistent with respect to reflective rumination. Recent research suggests reflective rumination might be associated with increased suicide risk specifically among vulnerable individuals. Poor sleep quality is related to both suicide risk and rumination, yet no research has examined whether reflective rumination and sleep quality interact in relation to suicidal risk. This study, therefore, examined whether sleep quality moderates the link between ruminative subtypes and (a) suicide risk overall, and (b) suicidal ideation and (c) history of suicide attempts, specifically. METHODS: Participants were 1696 college students (ages 18-29 years; 65% female) who completed measures assessing rumination, sleep, and suicidal ideation and behavior. Hierarchical linear and logistic regressions were performed regressing overall suicide risk (linear), suicidal ideation (linear) and history of attempts (logistic) on ruminative subtypes controlling for demographics. Sleep quality was examined as a moderator of the rumination-suicide risk/ideation/attempts link. RESULTS: Brooding rumination was significantly associated with increased suicide risk, ideation, and attempts but these associations were not moderated by sleep quality. Sleep quality exacerbated the association of reflective rumination with overall suicide risk and suicidal ideation specifically. Reflective rumination was not itself, or in interaction with sleep quality, significantly associated with a history of suicide attempts. LIMITATIONS: The study is cross-sectional and utilizes a college student sample. CONCLUSIONS: This study adds to the literature that suggests reflective rumination is associated with suicide risk and ideation in certain cases, such as in individuals with lower sleep quality. In addition, the study adds continued support for an association between brooding rumination and suicidal behaviors. More studies that examine the relations between ruminative subtypes and attempts are needed. Interventions that target sleep problems and rumination may be beneficial for suicide prevention and intervention.

Sluggish cognitive tempo and student-teacher relationship quality: Short-term longitudinal and concurrent associations.

Although sluggish cognitive tempo (SCT) is associated with poorer peer functioning, no study has examined SCT in relation to student-teacher relationship quality. The current study examined whether SCT, as rated by both teachers and children, was uniquely associated with poorer student-teacher relationship quality above and beyond child demographics and other mental health symptoms (i.e., attention-deficit/hyperactivity disorder [ADHD], oppositional defiant disorder/conduct disorder [ODD/CD], anxiety/depression). Gender was examined as a possible moderator of the association between SCT and student-teacher relationship quality. Participants were 176 children in 1st-6th grades and their teachers. Teachers rated children's SCT and other mental health symptoms in the fall semester (T1) and the student-teacher relationship (conflict and closeness) 6 months later (T2). Children provided self-ratings of SCT at T2. Above and beyond age, gender, and other mental health symptoms, teacher-rated SCT at T1 was associated with greater student-teacher conflict at T2. This association was qualified by a SCT × Gender interaction, with SCT associated with greater conflict for girls but not boys. Further, child-rated SCT was also associated with greater teacher-rated conflict, above and beyond covariates. In addition, teacher-rated SCT at T1 was the only mental health dimension to be significantly associated with less student-teacher closeness at T2. Findings extend the social difficulties associated with SCT to the student-teacher relationship, an important relationship associated with children's academic and socioemotional outcomes. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Sleep problems and suicidal behaviors in college students.

Using a large sample of college students, objectives were to examine (1) the overlap between poor sleep and suicide risk status, (2) whether poor sleep was associated with suicide behaviors above and beyond depression, (3) whether sleep problems and depression interacted to predict increased suicidal behaviors or risk, and (4) which specific components of sleep were uniquely associated with suicidal behaviors. Participants were 1700 college students (ages 18-29 years; 65% female) from two universities who completed measures assessing sleep, depressive symptoms, and suicidal behaviors (Suicidal Behaviors Questionnaire-Revised [SBQ-R], a composite measure including ideation, past attempt, disclosure to others, and future likelihood of suicide that includes a cutoff for determining participants with suicide risk). Approximately one-quarter (24%) of participants were classified with suicide risk. Four-fifths (82.7%) of participants classified with suicide risk also met cutoff criteria for sleep problems; conversely, almost one-third (31.3%) of the participants classified with sleep problems were also classified with suicide risk. Total sleep problems remained significantly associated with suicidal behaviors above and beyond depressive symptoms, though sleep and depression did not interact to predict suicidal behaviors or risk. When considered together and controlling for sex, the odds of being classified with suicide risk were 6.54 times greater for participants with elevated depressive symptoms and 2.70 times greater for participants with sleep problems. Analyses examining specific sleep domains found shorter sleep duration, having bad dreams, feeling too cold while sleeping, and sleep medication use to each be independently associated with suicidal behaviors. Findings add to a growing body of literature linking sleep and suicide in college students.

An exploratory study of the combined effects of orally administered methylphenidate and delta-9-tetrahydrocannabinol (THC) on cardiovascular function, subjective effects, and performance in healthy adults.

Methylphenidate (MPH) is commonly prescribed for the treatment of Attention Deficit Hyperactivity Disorder (ADHD), and is often used illicitly by young adults. Illicit users often coadminister MPH with marijuana. Little is known about physiologic and subjective effects of these substances used in combination. In this double-blind, cross-over experiment, sixteen healthy adult subjects free from psychiatric illness (including ADHD) and reporting modest levels of marijuana use participated in 6 experimental sessions wherein all combinations of placebo or 10mg oral doses of delta-9-tetrahydocannibinol (THC); and 0mg, 10mg and 40 mg of MPH were administered. Sessions were separated by at least 48 hours. Vital signs, subjective effects, and performance measure were collected. THC and MPH showed additive effects on heart rate and rate pressure product (e.g., peak heart rate for 10mg THC+0mg, 10mg, and 40 mg MPH=89.1, 95.9, 102.0 beats/min, respectively). Main effects of THC and MPH were also observed on a range of subjective measures of drug effects, and significant THC dose × MPH dose interactions were found on measures of "Feel Drug," "Good Effects," and "Take Drug Again." THC increased commission errors on a continuous performance test (CPT) and MPH reduced reaction time variability on this measure. Effects of THC, MPH, and their combination were variable on a measure of working memory (n-back task), though in general, MPH decreased reaction times and THC mitigated these effects. These results suggest that the combination of low to moderate doses of MPH and THC produces unique effects on cardiovascular function, subjective effects and performance measures.

Incremental benefits of a daily report card intervention over time for youth with disruptive behavior.

This study examined the percentage of children who respond positively to a daily report card (DRC) intervention and the extent to which students achieve incremental benefits with each month of intervention in a general education classroom. Participants were 66 children (87% male) with attention-deficit hyperactivity disorder or disruptive behavior problems who were enrolled in a school-based intervention program in rural, low-income school districts in a Midwest state. The DRC was implemented by each child's teacher, who received consultation from a graduate student clinician, school district counselor, or school district social worker. A latent class analysis using growth-mixture modeling identified two classes of response patterns (i.e., significant improvement and significant decline). Results indicated that 72% of the sample had all of their target behaviors classified as improved, 8% had all of their targets classified as declining, and 20% had one target behavior in each class. To examine the monthly incremental benefit of the DRC, individual effect sizes were calculated. Results for the overall sample indicated that most children experience a benefit of large magnitude (.78) within the first month, with continued incremental benefits through Month 4. The differential pattern of effect sizes for the group of improvers and the group of decliners offer data to determine when and if the DRC should be discontinued and an alternative strategy attempted. Evidence-based guidelines for practical implementation of the DRC are discussed.

Smoking withdrawal symptoms are more severe among smokers with ADHD and independent of ADHD symptom change: results from a 12-day contingency-managed abstinence trial.

INTRODUCTION: Smokers with attention deficit hyperactivity disorder (ADHD) have greater difficulty quitting than those without ADHD, but preliminary data (McClernon, Kollins, Lutz, Fitzgerald, Murray, Redman, et al., 2008) suggest equivalent severity of withdrawal symptoms following brief abstinence. The objective of this study was to characterize the differential effects of intermediate term smoking abstinence on self-reported withdrawal and ADHD symptoms in adult smokers with and without ADHD. METHODS: Forty adult (50% female), nontreatment seeking moderate-to-heavy smokers with and without ADHD were enrolled in a 12-day quit study in which monetary incentives were provided for maintaining biologically verified abstinence. Self-reported withdrawal, mood, and ADHD symptoms were measured pre- and post-quitting. RESULTS: ADHD and controls did not vary on smoking or demographic variables. Significant Group × Session interactions were observed across a broad range of withdrawal symptoms and were generally characterized by greater withdrawal severity among ADHD smokers, particularly during the first 5 days of abstinence. In addition, Group × Sex × Session interactions were observed for craving, somatic symptoms, negative affect, and habit withdrawal; these interactions were driven by greater withdrawal severity among females with ADHD. Group × Session interactions were not observed for ADHD symptom scales. CONCLUSIONS: The results of this study suggest that smokers with ADHD, and ADHD females in particular, experience greater withdrawal severity during early abstinence-independent of effects on ADHD symptoms. Whereas additional research is needed to pinpoint mechanisms, our findings suggest that smoking cessation interventions targeted at smokers with ADHD should address their more severe withdrawal symptoms following quitting.