Mary Victoria Solanto - US grants

It has been postulated that the primary deficit of the child with Attention Deficit Disorder with Hyperactivity (ADD-H) is a reduced sensitivity to reinforcement and punishment. This hypothesis has been examined in a few studies, with inconsistent results, and there has been virtually no investigation of the effects of contingency manipulation on inhibitory ability. Three studies are proposed here to address these issues: Study 1 will examine the differential effects of Reward and Punishment in ADD-H children and Normals on a test of inhibitory ability. Eighteen young (6-8 years) and eighteen older (9-12 years) ADD-H children and their matched normal controls will be assigned to receive Reinforcement for a successful delayed response, Punishment (response cost) for an impulsive response, or Feedback only on the Delay Task of the Gordon Diagnostic System/GDS. Study 2 will examine and compare the effects of applying contingencies for accuracy vs. latency to response on performance on the Matching Familiar Figures Test (MFF-20). Sixty ADD-H subjects and their matched controls will be assigned to receive one the following treatments: reinforcement for an accurate response, punishment (response cost) for an inaccurate response, reinforcement for a reflective response, punishment for an impulsive response, feedback only or no treatment. Finally, in Study 3, we propose to examine the effects of varying reward: punishment ratios on the Vigilance Task of the GDS. Eighty ADD-H subjects and their matched controls will be assigned to receive reinforcement for correct detections, one of 3 levels of punishment for a false positive response (error of commission), no treatment, or one of 4 possible combinations of reward and punishment. A signal detection analysis of the data will be employed. Anticipated benefits of these studies include a better understanding of the role of sensitivity to reinforcement/punishment in Attention Deficit Disorder with Hyperactivity, and information which may be useful in the design of improved behavioral interventions.

This application seeks to compare the neurocognitive functioning of attention deficit/hyperactivity disorder (AD/HD) subtypes: predominantly inattentive (IN), predominantly inattentive and predominantly hyperactive-impulsive combined (CB), introduced by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), as well as a normal control group with respect to attention, memory, inhibitory control, and executive functions. These measures have been selected to maximize the likelihood of identifying the neuropsychological processes and particular brain regions that may mediate the specific deficits.

DESCRIPTION (Applicant's abstract): The Inattentive subtype (IN) of Aftention-Deficit/Hyperactivity Disorder was newly defined in DSM-IV (1994). Recent epidemiological studies suggest that IN is at least as common and as impairing academically and socially as the more commonly recognized Combined type (CB). However, little is known about the etiology, course and outcome, or treatment of the IN type. Notably, although stimulant drugs are commonly used clinically to treat the disorder, there have been no systematic studies of its efficacy in the IN subtype. Differences between the IN and CB subtypes in behavioral phenotype, as well as in gender ratio, age of onset, and comorbidity suggest there may be critical differences in neurobiology, which may have relevance for response to drug treatments. The lack of data concerning stimulant drug efficacy in the IN type thus constitutes an important issue from the perspective of public health and quality of care. The proposed research is responsive to the current RFA in that it will study the efficacy of an established treatment (stimulants) in a new patient population (the IN subtype). The proposed project will assess and compare the response of the IN and CB subtypes to placebo and low, medium, and high doses of immediate-release methylphenidate in a double-blind crossover trial with one week of exposure to each condition. Order of conditions will be counterbalanced. Twenty-four male and female children between the ages of 7 and 12 will be enrolled in each group. Outcome measures will include weekly ratings by parents and teachers on wellnormed measures of ADHD symptoms and functional impairment previously shown to be drug-sensitive (Conners and SKAMP scales). In addition, children will be examined and rated weekly by a child psychiatrist on a measure of Clinical Global Improvement. A second specific aim is to test a hypothesis, emerging from a review of the literature, of divergence between dose-response curves for effects on activity and attention. We predict that the dose that optimizes performance on ratings of hyperactivity-impulsivity will be lower than that which optimizes performance on ratings of attention. We will similarly examine whether differences in dose-response curves for specific functions extend to differences between subtypes in optimal dose. The final aim of the current study is to compare the IN and CB subtypes with respect to selected measures of neurocognitive function on placebo and in response to drug treatment. We predict that the IN subtype will perform more poorly on measures of spatial orienting and stimulus encoding, whereas the CB subtype will show greater deficits on measures of cognitive inhibitory control, and that both types of cognitive deficit will respond to drug treatment.

[unreadable] DESCRIPTION (provided by applicant): Adults with ADHD experience significant impairment in social, emotional, occupational and academic functioning as a result of problems with the control of attention and impulses, as well as related impairment in everyday self-management functions of time-management, organization, and planning. There has been very little controlled investigation of the efficacy of psychosocial treatments to treat ADHD-related problems in adults. Stimulant and non-stimulant (atomoxetine) medications alleviate core symptoms of ADHD in adults. However, there is little evidence concerning the impact of these drugs on everyday self-management ("meta-cognitive") functions and clinical experience indicates that drug treatment is inadequate to remedy these problems. Furthermore, as many as one-third or more of adults may have an inadequate response to drug treatment, necessitating other forms of intervention. The specific aims of the proposed research, therefore, are to (a) develop and assess the efficacy of a focused 12-week manualized cognitive-behavioral group intervention to treat problems of time-management, organization, and planning in adults with ADHD; (b) to assess the indirect effects of the treatment on depression, anxiety, and self-esteem, (c) to examine maintenance of gains 6-months post-treatment. Eight-four adults with DSM-IV diagnoses of ADHD will be randomly assigned to receive either group CBT or a support (control) group. Outcome will be assessed on the basis of self- and observer report on the relevant scales of the Conners Adult Attention Rating Scale, the Brown ADD Scale, and ratings by a clinician blind to group status. This treatment development study will serve as the basis for an R01 application for a larger-scale assessment of the effects and mechanisms of cognitive-behavioral treatment (CBT) for the treatment of self-management problems that will also examine efficacy in different subgroups of AD/HD adults - with and without concurrent medication for AD/HD, those with and without comorbid anxiety or depression, and those differing in AD/HD subtype. [unreadable] [unreadable] [unreadable]

An estimated 8% of students on US college campuses have ADHD, accounting for 25% of students with disabilities. College students with ADHD experience significant academic impairment, including lower grade point averages (GPA's); increased frequency of probation, medical leave, and required withdrawal; and lower graduation rates. These adverse experiences likely contribute to the higher rates of depression and anxiety among college students with ADHD, as well as long-term occupational impairment. Poor executive self- management is increasingly recognized as a central characteristic of ADHD and a major cause of functional impairment at school and at work. Executive dysfunction in ADHD is typically manifested as deficient self- management with respect to time, organization, and planning, and correlates with worse academic performance in children with ADHD, and greater occupational impairment in adults. Although cognitive- behavioral therapy (CBT) is efficacious in treating executive dysfunction in adults with ADHD, efforts to adapt this intervention for the needs of college students have been sparse. The Specific Aims of this application are therefore: (1) to adapt our successful adult group CBT to address impaired executive self-management in college students with ADHD; (2) to train campus learning disability specialists to deliver the intervention (3) to examine the feasibility, acceptability, and effectiveness of the optimized intervention vis-à-vis ADHD symptoms, executive self-management, academic performance, and emotional outcomes and (4) to examine change in executive self-management as a critical mediator between proximal behavioral/cognitive changes and the therapeutic outcomes of interest. CBT will be delivered to rigorously evaluated and diagnosed students with ADHD at our collaborating site - the Weingarten Learning Resources Center (WLRC) for students at the U of PA. The first half of the project will be a Development phase, during which the 10-week group program (6-8 students) will be adapted and refined and during which three WLRC staff will be trained to deliver the intervention. During the Pilot Study, 84 eligible students will be randomized to receive either CBT or Treatment as Usual. The final manualized CBT protocol will be delivered in six 10-week treatment series, each led independently by one of the trainees. Pre- to post-treatment change will be assessed on measures of: (1) academic performance; (2) ADHD DSM-5 inattentive symptoms (3) executive self-management; and (4) depression, anxiety, and self-esteem. Information concerning the acceptability, feasibility, and scalability of this program on college campuses will be collected from 3 sets of stakeholders: 1) the student-participants 2) the WLRC trainees and Advisory Board and 3) the Investigators. We will also survey counseling/disability centers concerning the potential feasibility and utility of implementing the intervention with respect to resources, staffing, and training. Compiling this information is expected to facilitate interim projections about the feasibility of a full-scale multi-site trial of the intervention, and its scalability to college campuses generally.