Unfortunately, it was not possible for our experts to answer all questions posed during the hour-long seminar. Professor Edmund Sonuga-Barke has taken the time to respond to your questions on "Psychological Approaches to Treatment and Diagnosis". Find the responses here.
1 | Given that meta-analyses show that properly controlled studies find small or no effects of non-pharma treatments on ADHD, when should these treatments be used in the absence of medication?
The benefits of cogntive training and neuro-feedback for ADHD-related cognitive deficits remain uncertain - meta-analyses show benefits of WM training on WM - evidence for the benefits of neuro-feedback in this regard remain uncertain.
2 | How effective are psycho-social treatments compared to stimulant medication? Are they best when combined or is it a case of individual differences in responses to both types of treatments?
A meta-analysis (Van der Oord S et al., Clin Psychol Rev. 2008) evaluated both methylphenidate and psychosocial treatments. However, this meta-analysis did not distingush blinded from non-blinded outcomes - so I would be cautious about interpreting the effects of psycho-social treatments.
3 | How long to the effects seen from CBT last after therapy ends?
Previous one-year follow-up study (Boyer BE et al. Eur Child Adolesc Psychiatry. 2016) showed the treatment effect of CBT for ADHD children and initial improvements remained stable or continued to improve from posttest to 1-year follow-up. 25.9 % of adolescents showed normalized functioning.
4 | I would like to hear experts thoughts on specific ADHD coaching in comparison to a good broader CBT approach for ADHD patients.
A good head-to-head study is warrented.
5 | The right school and the understanding of the teachers for these children are very often missing here in Switzerland. They are often very intelligent but do not work according to the "norm". We involve the family. Should we also involve the school even more? What do you advise?
Yes - without a doubt. ADHD impacts on functioning in schools with long term cosequences. Reasonable adjustments should be encouraged.
6 | Are there any risks or side effects with psychosocial interventions for ADHD?
This is an important area for future research.
7 | Can the panel talk to the essential overlap between attachment differences (relational dysregulatory patterns) and neurodevelopmental difficulties? There seems to be a lack of relational approaches to assisting neurodiverse individuals with their own holistic development.
I agree with the sentiment of the question. A more wholistic approach is needed that take into acccount the psychological impact of ADHD the self concept and broader aspects of the internal life of people with ADHD. Having ADHD can have a crippling effect on children relationships including the very earlist ones with parents.
8 | Given the challenges of individuals with ADHD with emotioanl dysregualtion, would a hybrid CBT / DBT model useful, as a follow up question: Which componets of exectuive dysfunction are taregeted more effectively with psycosical interventions?
Psychosocial interventions with children with ADHD can have a positive effect on some executive functions like visuospatial memory and planning.
9 | Which psychosocial interventions do you recommend?
I think psychosocial intervention are best used for associated problems rather than core symptoms - so I would base decisions on what are the associated problems.
10 | Do you think trauma and/or insecure attachment is a cause of ADHD?
In general its seems unlikely that trauma is a cause of ADHD but rather than ADHD leads to a higher incidence of trauma - there are exceptions say in realtion to severe negelct/deprivation. However, I agree that that trauma represents a potentially important clinical context. Parental attachment problems and environmental mediating factors were significantly associated with childhood ADHD. Adults with ADHD had a much higher incidence of insecure attachment styles than reported in the general population.
11 | What kind of differences do you see in terms of gender differences in adults with ADHD? In terms of presentation of the disorder, needs of the individuals, in acceptance of CBT or in response to CBT?
This area need so much more research - it’s a top priority.
12 | Long term stimulant use is beneficial for the adhd brain so medication could cure ADHD if started early. So why should CBT be preferred to medication? - taken from Wikipedia: in humans with ADHD, pharmaceutical amphetamines, at therapeutic dosages, appear to improve brain development and nerve growth. Reviews of magnetic resonance imaging (MRI) studies suggest that long-term treatment with amphetamine decreases abnormalities in brain structure and function found in subjects with ADHD, and improves function in several parts of the brain, such as the right caudate nucleus of the basal ganglia.
I think the claim that early medication cures ADHD is highly speculative and dubious and should be taken off wikipedia. There has been no relevant long term prevention RCT to test this hypothesis in humans.
13 | Let's keep in mind that withholding medication to try a behavioral treatment could lead to adverse ADHD outcomes such as accidents. Isn't that an adverse effect of psychosocial treatments?
Both psychotherapy and medication have pros and cons. In the process of adjusting the clinical treatment plan, it is necessary to weigh the risks of drug treatment and non-drug treatment and try to avoid the harm caused by delayed treatment. Different treatment methods are used according to different ages of children with ADHD.
14 | Why does cognitive training have such a limited effect on ADHD symptoms?
Good question - it may be that genetically based developmental brain deficits are less responsive to remidation than acquired lesions.
15 | What is your opinion on group sessions for parents/caregivers of preschool Kindergarten children?
Very useful to imporve parenting and reduce the negative context in which people with ADHD grow up which can impact their development very significantly.
16 | How about CBT (Cognitive Behavior Therapy) approach for ADHD? Is it effective?
I think we need better trials with blinded outcomes.
17 | Any work on cognitive bias modification - changing the interpretive bias about everyday interactios (which is usually negative in adolecents with ADHD) rather than CBT?
We did some work looking at cognitve bias' in ADHD suggesting altered motivational responses to threat - this I sprobably a secondary effect - but it would be good to try to see if they can modified to reduce long term negative risk for anxiety etc.
18 | My reading of the literature indicates that it is not true that behavior therapy works well for kids as regards treating ADHD symptoms. Would you please give a comment?
You may be thinking about the results of the meta-analysis published by Sonuga-Barke et al in 2013, which showed that whereas the effect size for all studies of parent management training on ADHD symptoms was significant with good effect sizes of .40-.64, the results for the subset of studies in which the raters were "probably blinded" was non-significant. It is important to keep in mind here, however, that it is difficult to create a control condition for PMT when the parents (or teachers) are necessarily the ones delivering the treatment as well as rating the outcomes. The largest and best studies of PMT, including the MTA, have not accomplished that. There may be some consolation in the follow-up meta-analysis by Daley...Sonuga-Barke (2014) on the same data, that found significant effects for other outcomes, as follows, and these remained significant even when limited to studies that were "probably blinded."
•Parenting quality : SMD = 0.68***
•Negative Parenting: SMD=0.57 ***
•Conduct Problems (SMD=0.26)***