Marcela C. Ramos

Aggressive behavior in childhood is a major developmental and educational concern, but school discipline records provide limited information about how aggression is identified and managed in everyday settings. This study used direct observation to characterize office discipline referral (ODR) events among kindergarten through fifth-grade students in 2007, with each of 14 schools observed for one designated week near the end of a randomized school-based intervention trial. Observers recorded 348 referrals involving 296 students. Aggressive or destructive behavior—physical aggression, verbal aggression, or property destruction—accounted for 46.8% of referrals, with physical aggression alone accounting for 38.5%. Aggressive/destructive referrals involved descriptively longer office stays than other referrals, although the within-school difference was smaller and imprecisely estimated after accounting for school-level clustering. Fifth grade had the highest overall referral rate, whereas kindergarten referrals were proportionally most likely to involve aggressive/destructive behavior. Exploratory matched-pair comparisons provided little evidence of differences between intervention and comparison schools in aggressive/destructive referral rates, although some differences in referral composition and prolonged office stays remained imprecisely estimated. ODRs capture a consequential but selective subset of childhood aggression: behavior that is observed, interpreted, and formalized through school disciplinary procedures.

Evidence-based treatments for childhood attention-deficit/hyperactivity disorder (ADHD) include behavioral treatment and psychostimulants, preferably in combination. Research on the treatment of ADHD underscores a gap in the literature regarding the optimal sequencing of treatments (Pelham, Jr. & Altszuler, 2020). Emerging evidence supports starting with behavioral treatment before psychostimulants, though the mechanisms of this sequencing effect are not entirely understood. This study explores one plausible mechanism-that psychostimulants reduce behaviors targeted by behavioral treatment, thereby reducing opportunities for children to learn and practice self-regulation skills. The article reports post hoc findings from a triple-masked, AB/BA crossover study, conducted in the Summer Treatment Program (STP). Two-hundred forty-eight children diagnosed with ADHD; 77% male; 85% Hispanic) were randomized to receive either (a) intensive behavior therapy plus medication ("COMB") or (b) intensive behavior therapy plus placebo ("BT") for 3 weeks, then crossed over to the other condition for 3 weeks. Behavior in recreational settings was systematically recorded and analyzed as a function of medication status and order of treatments. We found evidence that initial medication reduced the efficacy of subsequent behavior therapy. That is, children exhibited significantly more misbehaviors when unmedicated if they started with combined treatment, then had medication withdrawn, than if they started with behavior therapy alone. These findings suggest that starting with a combined treatment approach had an unintended adverse impact on children's behavioral functioning when medication was withdrawn. The results support current clinical recommendations, which are to start treatment of ADHD with behavior therapy alone and to add medication as necessary.

Attention-deficit/hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder defined by pervasive symptoms of inattention, hyperactivity, and impulsivity. Furthermore, children with ADHD show marked deficits in executive functioning (EF) such as attention, effortful control, and behavior, and are more likely to have poor self-regulatory skills. Current evidence-based interventions for children with ADHD include behavioral treatment (BT), psychopharmacological treatment, and their combination. Many other interventions are often used conjunction with or in lieu of evidence-based treatments for ADHD. One such example is the use of mindfulness-based interventions which have been shown to improve attention, reduce maladaptive behaviors, and increase self-regulatory abilities among children in general education settings. The current study is the first to evaluate the effect of mindfulness intervention in combination with BT on behavior, task-based executive functioning (EF), and mindful awareness in elementary-aged children with ADHD (N = 58). The study took place in a controlled analogue summer program setting (STP) in which children were randomized to receive either the mindfulness intervention in conjunction with BT or to a BT active control condition. Children completed a variety of EF cognitive tasks at baseline and post-treatment. Child behavioral responses were measured as teacher and staff-recorded frequencies of observed behavior. In addition, parent-reported and child self-reported measures on mindful awareness were collected. Overall, there were no beneficial incremental effects of mindfulness when used in combination with intensive BT with regard to observed child behavior, attention and inhibitory control, or mindful awareness.

Evaluate whether stimulant medication improves acquisition of academic material in children with ADHD receiving small-group, content-area instruction in a classroom setting. Participants were 173 children between the ages of 7 and 12 (77% male, 86% Hispanic) who met DSM −5 criteria for ADHD and were participating in a therapeutic summer camp. The design was a triple-masked, within-subject, AB/BA crossover trial. Children completed two consecutive phases of daily, 25-minute instruction in both (a) subject-area content (science, social studies) and (b) vocabulary. Each phase was a standard instructional unit lasting for 3 weeks. Teachers and aides taught the material to small groups in a summer classroom setting. Each child was randomized to be medicated with daily osmotic-release oral system methylphenidate (OROS-MPH) during either the first or second of the instructional phases, receiving placebo during the other. Medication had large, salutary, statistically significant effects on children’s academic seatwork productivity and classroom behavior on every single day of the instructional period. However, there was no detectable effect of medication on learning the material taught during instruction: children learned the same amount of subject-area and vocabulary content whether they were taking OROS-MPH or placebo during the instructional period. Acute effects of OROS-MPH on daily academic seatwork productivity and classroom behavior did not translate into improved learning of new academic material taught via small-group, evidence-based instruction.

The conceptual overlap between mind-wandering and attention-deficit/hyperactivity disorder (ADHD)-related impairments is considerable, yet little experimental research examining this overlap among children is available. The current study aims to experimentally manipulate mind-wandering among children with and without ADHD and examine effects on task performance. Participants were 59 children with ADHD and 55 age-matched controls. Participants completed a novel mind-wandering sustained attention to response task (SART) that included non-self-referential and self-referential stimuli to experimentally increase self-referential mind-wandering, reflected by increases in reaction time variability (RTV) following self-referential stimuli. The ADHD group participated in a classroom study with analogue conditions aimed at encouraging self-referential future-oriented thinking (free play/movie before and after class work) compared to a control condition (newscast) and a cross-over methylphenidate trial. The significant interaction between ADHD status and self-referential stimuli on SART performance indicated that self-referential stimuli led to greater RTV among children with ADHD (within-subject d = 1.29) but not among controls. Methylphenidate significantly reduced RTV among youth with ADHD across self-referential (d = 1.07) and non-self-referential conditions (d = 0.72). In the ADHD classroom study, the significant interaction between mind-wandering condition and methylphenidate indicated that methylphenidate led to higher work completion (ds > 5.00), and the free-play mind-wandering condition had more consistent detrimental effects on productivity (ds ≥ 1.25) than the movie mind-wandering condition. This study is the first to manipulate mind-wandering and assess effects among children with ADHD using a behavioral task. Results provide evidence that children with ADHD are uniquely susceptible to mind-wandering interference.

Interventions for attention-deficit/hyperactivity disorder (ADHD) include positive behavior supports (e.g., parent training, school-based contingency management, behavioral peer interventions), training interventions (e.g., organizational skills training, social skills training, etc.), and other interventions (e.g., academic accommodations/modifications, self-monitoring). There is a need to conduct a comprehensive meta-analysis of psychosocial treatments for ADHD given discrepancies between meta-analyses. The present meta-analysis reports the results of between-group studies that compared a psychosocial treatment to a control condition from 1968 to 2016. In total, 226 studies were identified that met inclusion criteria. Results of the meta-analysis were organized by treatment type, rater, and domain of outcome assessed. Results indicated considerable variability across these parameters, with the strongest effects for proximal outcomes of behavioral parent training (improvements in parenting behaviors yielded a standardized mean difference of 0.70) and improvements in child behavior following implementation of behavioral school intervention (standardized mean difference of 0.66 and 0.72 for teacher ratings of ADHD symptoms and impairment, respectively). Other interventions were not extensively studied as stand-alone approaches. Results are discussed in light of current support for the use of psychosocial interventions for individuals with ADHD.