Objective Behavioral and pharmacological treatments for children with ADHD were evaluated to address whether endpoint outcomes are better depending on which treatment is initiated first, and, in case of insufficient response to initial treatment, whether increasing dose of initial treatment or adding the other treatment modality is superior. Methods Children with ADHD (ages 5–12, N = 146, 76% male) were treated for one school year. Children were randomized to initiate treatment with low doses of either (a) behavioral parent training (8 group sessions) and brief teacher consultation to establish a Daily Report Card or (b) extended-release methylphenidate (equivalent to .15 mg/kg/dose bid). After 8 weeks or at later monthly intervals as necessary, insufficient responders were rerandomized to secondary interventions that either increased the dose/intensity of the initial treatment or added the other treatment modality, with adaptive adjustments monthly as needed to these secondary treatments. Results The group beginning with behavioral treatment displayed significantly lower rates of observed classroom rule violations (the primary outcome) and parent/teacher ratings of oppositional behavior at study endpoint and tended to have fewer out-of-class disciplinary events. Further, adding medication secondary to initial behavior modification resulted in better outcomes on the primary outcomes and other measures than adding behavior modification to initial medication. Normalization rates on teacher and parent ratings were generally high. Parents who began treatment with behavioral parent training had substantially better attendance than those assigned to receive training following medication. Conclusions Beginning treatment with behavioral intervention produced better outcomes overall than beginning treatment with medication.

We investigated participants’ task set preparation by measuring changes in pupil diameter during a blank interval as they prepared for an easy (i.e., prosaccade) or difficult (i.e., antisaccade) trial. We used occasional thought probes to gauge “on-task” thoughts versus mind wandering. In both studies, participants’ pupil diameters were larger when anticipating an antisaccade, relative to a prosaccade, trial. In contrast, their self-reported mind wandering depended upon whether the thought probes occurred after their target detection response (Experiment 1) or occurred in lieu of target detection (Experiment 2). In the latter case, self-reported mind wandering echoed the pupil diameter changes in demonstrating greater off-task behavior when preparing for a prosaccade trial. More important, trial type effects in pupil diameter emerged only when participants reported being “on-task,” but disappeared during periods of mind wandering. These results demonstrate that changes in pupil diameter reflect the degree of preparatory control exerted for an upcoming trial, but only when attention is actively focused on the upcoming task.

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This study sought to systematically examine the academic behavior of children with ADHD in different instructional contexts in an analogue classroom setting. A total of 33 children with ADHD participated in a reading comprehension activity followed by a testing period and were randomly assigned within days to either small-group instruction, whole-group instruction, or independent seatwork. The effects of instructional contexts on on-task behavior during instruction and on-task behavior and work productivity during testing were examined. Children with ADHD were found to be more on task during small-group instruction than both whole-group and independent seatwork instructional conditions. In the testing context, children with ADHD were found to be less productive in small-group than in the whole-group and independent seatwork conditions. The findings of this study have implications for future research evaluating the standard educational practices and accommodations made for children with ADHD in the classroom setting.

By encouraging self-expression and empowering class participants, the class was refined to be used for research purposes to gain further insight into the problems faced by persons living with stroke.

Objective We conducted a cost-analysis of the behavioral, pharmacological, and combined interventions employed in a sequential, multiple assignment randomized, and adaptive trial investigating the sequencing and enhancement of treatment for ADHD children (Pelham et al., under review; N=152, 76% male, 80% Caucasian). Methods The quantity of resources expended on each child’s treatment was determined from records that listed the type, date, location, persons present, and duration of all services provided. The inputs considered were the amount of physician time, clinician time, paraprofessional time, teacher time, parent time, medication, and gasoline. Quantities of these inputs were converted into costs in 2013 USD using national wage estimates from the Bureau of Labor Statistics, the prices of 30-day supplies of prescription drugs from the national Express Scripts service, and mean fuel prices from the Energy Information Administration. Results Beginning treatment with a low-intensity regimen of behavior modification (group parent training) was less costly for a school-year of treatment ($961) than beginning treatment with a low dose of stimulant medication ($1689), regardless of whether the initial treatment was intensified with a higher “dose” or if the other modality was added. Conclusions Outcome data from the parent study (Pelham et al., under review) found equivalent or superior outcomes for treatments beginning with low-intensity behavior modification compared to intervention beginning with medication. Combined with the present analyses, these findings document that initiating treatment with behavior modification rather than medication is the more cost-effective option for children with ADHD.

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