Adults with attention-deficit/hyperactivity disorder (ADHD) are more frequently presenting for diagnosis and treatment. Medication is considered to be appropriate among available treatments for ADHD; however, the evidence supporting the use of pharmacotherapeutics for adults with ADHD remains less established. In this article, the effectiveness and dosing parameters of the various agents investigated for adult ADHD are reviewed. In adults with ADHD, short-term improvements in symptomatology have been documented through the use of stimulants and antidepressants. Studies suggest that methylphenidate and amphetamine maintained an immediate onset of action, whereas the ADHD response to the nonstimulants appeared to be delayed. At a group level, there appears to be some, albeit not entirely consistent, dose-dependent responses to amphetamine and methylphenidate. Generally speaking, variability in diagnostic criteria, dosing parameters and response rates between the various studies was considerable, and most studies were of a relatively short duration. The aggregate literature shows that the stimulants and catecholaminergic nonstimulants investigated had a clinically significant beneficial effect on treating ADHD in adults.

The link between Attention-deficit/Hyperactivity Disorder (ADHD) and substance use disorders (SUD) continues to be an area of great interest. In this report we discuss more recent work exploring the developmental relationship between ADHD and SUD and associated concurrent disorders. Recent work highlights the role of treatment of ADHD in children on subsequent cigarette smoking and SUD in adolescence and adulthood. Recent diagnostic issues examining ADHD in SUD populations are highlighted. Recent studies in patients with ADHD and SUD suggest that SUD treatment needs to be sequenced initially with ADHD treatment quickly thereafter.

Although psychotherapy is generally efficacious, a substantial number of patients fail to improve meaningfully, whereas still others deteriorate. Moreover, psychotherapists have difficulty forecasting which patients are at risk for nonresponse or deterioration, especially when relying predominantly on their judgment. These limitations have implications for the ethical practice of psychotherapy, and they call for remediation strategies. One such strategy involves the use of routine outcomes monitoring (ROM), or the regular collection of core patient progress information that can be fed back to the clinician and patient in real time. ROM-informed analytics outperform clinical judgment in predicting patients who are on or off track for treatment success, which can help psychotherapists plan and responsively adjust their interventions. Additionally, research demonstrates that ROM-generated feedback improves treatment outcomes for the average case who receives versus does not receive it. ROM data can also uncover between-therapist differences in general efficacy, as well as scientifically highlight clinicians' own relative strengths and weaknesses in treating different mental health problems. In light of such evidence, we submit that the research on ROM has matured to the point that it should occupy a central role in discussions of, and guidelines about, the ethical practice of psychotherapy. In this vein, we discuss ROM at patient, psychotherapist, and mental health care systems levels; namely, for each of these stakeholders, we review the extant empirical support before turning to possible ethical implications. Finally, we offer concluding thoughts on the expanding relevance of ROM for helping psychologists fulfill their ethical practice obligations. Clinical Impact StatementQuestion: After surveying relevant research, we discuss the growing role of routine outcomes monitoring (ROM) for helping psychotherapists and mental health care systems fulfill their ethical practice obligations, including maximizing patient benefit and minimizing harm. Findings: There is expanding evidence that ROM-generated information has the potential to improve treatment outcomes at the patient level (e.g., by identifying patients at risk of nonresponse or harm and informing clinician responsiveness to this signal), psychotherapist level (e.g., by helping to establish clinicians' objective strengths and weaknesses that could inform their selective practice and personalized training foci), and mental health care systems level (e.g., by referring patients to empirically good-fitting clinicians within a care network). Meaning: Research on ROM suggests that it should be considered in any discussion about the ethical practice of evidence-based psychotherapy. Next Steps: It will be important for clinical and research efforts to concentrate on increasing ROM implementation to fulfill ethical demands at the patient, psychotherapist, and systems levels.

SUMMARY A high prevalence of comorbidity of ADHD and substance-use disorders (SUDs) has been shown in the literature. In this article, the literature for the treatment of adolescents and adults with co-occurring ADHD and SUD is examined. Findings from pharmacotherapy suggest mild improvement in ADHD without demonstrable changes in SUD unless the addiction was stabilized prior to treating the ADHD. No unique adverse effects, worsening of SUD, misuse or diversion of stimulants are reported in the included studies. Treating ADHD pharmacologically in individuals with ADHD plus SUD only has a modest impact on ADHD and SUD that is not observed in controlled trials. Limited data in adults with ADHD and brief abstinence of their SUD showed improvements in both ADHD and SUD with treatment. Further studies of cognitive behavioral therapy, sequencing of therapies and longer term treatment outcomes for groups with ADHD and active SUD are necessary.

The therapeutic alliance is widely regarded as an empirically-based element of successful psychotherapy. However, the degree to which training programs incorporate alliance-centered components into their curricula and clinical practica remains unclear. The aims of this study were to explore (a) training programs’ awareness of research that establishes the alliance as a component of evidence-based practice; (b) the extent to which programs incorporate formal, evidence-based alliance training into their pedagogy; (c) what training programs would consider ideal alliance-training practices; and (d) whether there are differences in evidence-based alliance-training practices or perspectives between programs with different terminal degrees. Data derived from a quantitative survey of directors (or their designates; N = 84) of American Psychological Association-accredited clinical (Doctor of Philosophy or Doctor of Psychology) and counseling (Doctor of Philosophy) programs in the United States and Canada. Generally, respondents indicated that their programs were aware of alliance research trends. However, respondents also largely indicated that they do not incorporate systematic, evidence-based alliance training into their programs, despite believing that such systematic elements would contribute to ideal alliance-training practices. There were no statistically significant differences between program degree type in terms of awareness of alliance research, current alliance-training practices, or views on ideal alliance-training practices. We discuss the implications of the present results for training and future research directions.

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Although the therapeutic alliance is an evidence-based psychotherapy element, scant literature exists on best practices for alliance-focused training. This qualitative study explored the perspectives of 10 psychotherapy alliance researchers on current and ideal alliance-centered training approaches. Data derived from interview transcripts of the proceedings of 2 semistructured discussions at professional conferences. Results indicated that most participants viewed current alliance training as unstructured, while also expressing an interest in developing a more structured, gold standard approach. Participants also highlighted the psychotherapist's role in alliance development and the importance of clinicians' personal improvement strategies. Little consensus emerged concerning barriers to ideal alliance-training practices.

Objectives Despite increasing acknowledgement of Bipolar Disorder (BD) in childhood, there is a paucity of literature that has investigated obstetrical, perinatal, and infantile difficulties and their potential link with BD. To this end, we examined difficulties during delivery, immediate post-birth, and infancy and the association with BD in childhood. Methods From two similar-designed ongoing longitudinal, case-control family studies of pediatric BD (N=327 families), we analyzed 338 children and adolescents (mean age: 12.00 ± 3.37 years). We stratified them into three groups: healthy controls (N=98), BD probands (N=120), and their non-affected siblings (N=120). All families were comprehensively assessed with a structured psychiatric diagnostic interview for psychopathology and substance use. Mothers were directly questioned regarding the pregnancy, delivery, and infancy difficulties that occurred with each child using a module from the Diagnostic Interview for Children and Adolescents-Parent Version (DICA-P). Results Mothers of BD subjects were more likely to report difficulties during infancy than mothers of controls (Odds Ratio (95% CI) = 6.6 (3.0, 14.6)). Specifically, children with BD were more likely to have been reported as a stiffened infant (7.2 (1.1, 47.1)) and more likely to have experienced “other” infantile difficulties (including acting colicky; 4.9 (1.3, 18.8)) compared to controls. We found no significant differences between groups in regards to obstetrical or perinatal difficulties (all p values > 0.05). Conclusions While our results add to previous literature on obstetrical and perinatal difficulties and BD, they also highlight characteristics in infancy that may be prognostic indicators for pediatric BD.