Pediatric Neuroscience Pathways Fall 2012 - Cleveland Clinic

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we studied 25 children ages 6 to 12 years who participated in a seven-week summer treatment program. 1 the study used a unique experimental design that alternated treatments by day with children acting as their own controls. ratings and behavioral observations were conducted across the length of the day. three dependent measures were investigated: ratings of symptom reduction as measured by a scale commonly used in clinical trials, parent ratings of emotional dysregulation (i.e., frustration intolerance) and the ability of the child to follow instructions. the results indicated a unique set of findings: COM and MED conditions showed improvement over Beh treatment beginning three hours post-dose and maintained 12.5 hours post-dose for two of the dependent measures: overall symptom reduction and following instructions. Results for frustration tolerance, however, indicated significant improvement in all three conditions until nine hours post-dose. Medicine sustained benefit across the day for two of three measures, and behavior modification had an additive effect on frustration tolerance. the study addressed an important gap in the literature in that it examined the duration of effect of a long-acting medication alone relative to intensive behavior therapy alone relative to the combined effect of behavior therapy and long-acting medication. In contrast to randomized clinical trials, we used a small-N alternating treatments design2,3 in a quasi-naturalistic setting to compare active treatments rather than treatment vs. placebo alone. we were interested in when the effect of behavior therapy ends, and what, if any, augmentative effects emerge when behavior therapy is combined with long-acting medication. Most previous comparative Pediatric Behavioral health Comparing the Effectiveness of Stimulant and Behavioral Treatment in Youth with Attention-Deficit/Hyperactivity Disorder in a Quasi-Naturalistic Setting Michael J. Manos, PhD; Donald A. Caserta, MSSA; Elizabeth J. Short, PhD; Kimberly C. Giuliano, MD; and Thomas W. Frazier, PhD Attention-deficit/hyperactivity disorder (ADHD) affects 9.5 percent of children and about 4.5 percent of adults. As such, effective interventions are sought to assist people in managing symptoms to improve their quality of life. cleveland clinic’s center for Pediatric Behavioral health conducted a study to compare the relative effects of three treatment conditions: long-acting stimulant medication (MED), intensive behavior modification (BEH) and medication/ behavioral treatments combined (com) in children with adhd. the study was designed to answer two questions: 1. What is the relative effectiveness of behavioral intervention and long-acting medication in the treatment of ADHD? 2. What is the duration of effect of extended-release medication and behavior therapy across the day in a quasi-naturalistic setting? effectiveness studies focused exclusively on global improvement of symptoms using short-acting stimulants, and they seldom measured real-world behaviors using long-acting stimulants. Thus, little information is available on the relative effectiveness of MED, BEH and com. treatments in this study were implemented in a camp environment that approximates daily settings children experience in play and classrooms. As such, the present study represents an effectiveness extension to previously conducted efficacy trials. 4,5 Behavioral interventions are the other side of the adage “pills don’t teach skills.” From an ecological perspective, most would agree that psychosocial interventions are important to treating adhd in everyday settings such as classrooms, playgrounds and sports events. Previous effectiveness studies provide evidence that behavioral intervention enhances medical intervention by impacting co-occurring conditions such as anxiety. 6 we extend this to show that behavioral treatment also contributes to managing frustration in children with adhd. the observation that applied behavioral intervention as monotherapy sustained frustration tolerance as effectively as medicine suggests interesting differential effects of behavioral treatment. Frustration intolerance, a form of emotional dysregulation, is a free operant in that it occurs at irregular, unpredictable intervals. Because in the summer treatment program it is met with very consistent aversive consequences (labeling the behavior and loss of points), it can come under more rigorous and vigilant self-control by the child. This may indicate possible selective effects of behavioral intervention as a monotherapy for some children with adhd. 34 Pediatric NeuroscieNce Pathways | 2012 – 2013
figure 1. sKamP ratings by extended time and treatment mean sKamP: clinician item score by time by treatment condition mean item score 1.2 1.0 0.8 0.6 0.4 0.2 0.0 Pediatric Behavioral health Figure 1. Counselor SKAMP ratings across all time periods, separately for each treatment condition. Values represent mean item ratings. SKAMP = Swanson, Kotkin, Agler, M-Flynn, and Pelham rating scale; MED = lisdexamfetamine; BEH = behavioral modification; COM = combined MED + BEH Figure 2. Counselor Behavior Monitoring Scale-Parent ratings across all time periods, separately for each treatment condition. Values represent mean item ratings. MED = lisdexamfetamine; BEH = behavioral modification; COM = combined MED + BEH Michael J. Manos, PhD, is Head of Cleveland Clinic’s Center for Pediatric Behavioral Health. His specialty interests include attention-deficit/hyperactivity disorder, behavioral pediatrics, clinical behavioral pediatrics and pharmacotherapy research. He can be reached at 216.445.7574 or manosm@ccf.org. Donald A. Caserta, MSSA, is a staff member in Cleveland Clinic’s Center for Pediatric Behavioral Health; Elizabeth J. Short, PhD, is a professor in the Department of Psychology at Case Western Reserve University; Kimberly C. Giuliano, MD, is a Cleveland Clinic pediatrician; and Thomas W. Frazier, PhD, is a staff member in Cleveland Clinic’s Center for Pediatric Behavioral Health Autism Center. reFereNces 9:00 AM Beh com med 9:30 AM 11:30 AM 1:30 PM 3:30 PM 5:30 PM 7:00 PM 9:00 PM 7:00 PM time 1. Pelham WE, Gnagy EM, Greiner AR, et al. Behavioral versus behavioral and pharmacological treatment in adhd children attending a summer treatment program. J Abnorm Child Psychol. 2000 Dec;28(6):507-525. figure 2. following instructions BmsP: following instructions by treatment condition and time 2. Hersen M, Barlow D. Single-Case Experimental Designs: Strategies for Studying Behavior Change. New York, NY: Pergamon Press; 1976. 3. Kazdin ae. Single-Case Research Designs. New York, NY: Oxford University Press; 1982. 4. Gartlehner G. Hansen RA, Nissman D, Lohr KN, Carey TS. A simple and valid tool distinguished efficacy from effectiveness studies. J Clin Epidemiol. 2006;59:1040-1048. 5. Frazier TW, Weiss M, Hodgkins P, Manos MJ, Landgraf JM, Gibbins C. Time course and predictors of health-related quality of life improvement and medication satisfaction in children diagnosed with attention-deficit/hyperactivity disorder treated with the methylphenidate transdermal system. J Child Adolesc Psychopharmacol. 2010;20:355-364. 6. Jensen Ps. introduction — adhd comorbidity and treatment outcomes in the mta. J Am Acad Child Adolesc Psychiatry. 2001;40:134-136. visit clevelaNdcliNicchildreNs.org | 866.588.2264 35 mean cgi-s rating 2.4 2.2 2.0 1.8 1.6 time 9:00 PM com Beh med
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Page 7 and 8: cover story | diagNostic radiology
Page 9 and 10: suggested readiNg Wyllie E, Lachhwa
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Pediatric Neuroscience Pathways Fall 2012 - Cleveland Clinic

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