Professor Gail Tripp

Symposium

Motivation, emotion and ADHD

In this interesting symposium about motivation and emotion in ADHD, Professor Gail Tripp (Human Developmental Neurobiology Unit, OIST Children’s Research Center, Okinawa, Japan) began by discussing reward and punishment. Professor Tripp explained that children with ADHD have reduced and delayed anticipatory dopamine release, favouring smaller immediate rewards over greater delayed rewards.1 She also highlighted that although mild punishment may improve performance, children with ADHD show avoidance of scenarios where punishment is possible, which may lead to distraction from the task at hand.2

Dr Maddie Groom (Medicine and Health Sciences, University of Nottingham, UK) then presented results from the MIDAS study showing ongoing oscillations in the alpha frequency band are altered by motivational incentives in typically developing children, but not those with ADHD, and that specifc characteristics of these neural oscillations predict cognitive performance across subjects.3

Dr Anouk Scheres (Radboud University, Nijmegen, The Netherlands) went on to highlight that motivation can be intrinsic e.g. interest/passion or extrinsic e.g. deadlines, and by continually rewarding children with ADHD, we may undermine their intrinsic motivation. Finally, Professor Tobias Banaschewski (Child and Adolescent Psychiatry University of Heidelberg, Germany) concluded with a discussion of emotional dysregulation in children with ADHD, arguing that it cannot be fully explained by neuropsychological deficits and should not be considered a core symptom of ADHD.4

Professor Tripp: “We need to get over the idea we’re spoiling a child with reinforcement. We’re actually compensating for a biological shortfall.”

Dr Scheres: “The hidden cost of rewards…we know that rewards can distract attention away from the task and towards the reinforcer.”

Professor Luis Rohde



Professor David Coghill



ADHD World Federation Symposium

Controversies and challenges in ADHD research

In this symposium, Professor Luis Rohde (Department of Psychiatry, Federal University of Rio Grando do Sul, Porto Alegre, Brazil) began by discussing some of the priorities for future research in ADHD, including the need to understand more about disease heterogeneity and the different disease trajectories. He also highlighted that there is not currently a gold standard diagnostic process in ADHD, recommending that factors other than symptoms should be given more weight in the diagnostic process.

Professor Tobias Banaschewski (Child & Adolescent Psychiatry, University of Heidelberg, Mannheim, Germany) then shared his opinion that individualised treatment will be a key future topic and provided the audience with an overview of the study design of his research group’s ESCALIFE trial.

This was followed by a thought-provoking presentation from Professor Marcel Romanos (Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Würzburg, Würzburg, Germany), who highlighted a key methodological weakness in the recent Cochrane review, a publication which concluded that the quality of the evidence showing the efficacy of methylphenidate in ADHD was of very low quality, making it impossible to have confidence in the results.5 He concluded by saying that the review is not acceptable in its current form and should either be amended or withdrawn.

Finally, Professor David Coghill (Departments of Paediatrics and Psychiatry, University of Melbourne, Royal Children’s Hospital, Melbourne, Australia) concluded with some interesting perspectives regarding future clinical trials, for example, suggesting that we have many unanswered questions about the cognitive and gene-level effects of existing treatment. He concluded that researchers must work together in changing future trial designs to focus on aspects of ADHD other than core symptoms.

Professor Rohde: “I think that it is very difficult to just abandon everything about diagnosis. We need to begin to re-evaluate…and find some way to improve the validity of the diagnosis.”

Professor Coghill: “Long-term randomised controlled trials are not good enough…we should think of new powerful ways to collect data.”

Professor Jim Swanson

Plenary lecture

Multimodal treatment study of children with ADHD: outcome after 16 years

In this interesting lecture, Professor Jim Swanson (Department of Psychiatry, Florida International University, Miami, Florida, USA) provided an overview of the MTA study from its initial conception in 1993 to its present-day form as a long-term observational study with 16 years of follow-up data from patients with ADHD through childhood into adulthood.

In particular, he discussed some of the design difficulties they encountered and the controversies that the results generated over the years. During each stage of the presentation, Professor Swanson highlighted two key points: the importance of the finding that children with ADHD did not persist with medication over time; and the fact that although the MTA study cannot give us data on direct cause and effect, it is an excellent way to generate hypotheses for future research. Focusing on the present data emerging from the study,6,7 Professor Swanson concluded with a brief discussion of data pertaining to the persistence of ADHD in adulthood, and the long-term effects of medication on height and weight.

Professor Swanson: “These results are not for testing hypotheses, but for generating hypotheses.”

“The biggest effect we seemed to get in the MTA is that children don’t seem to stay on medication over time.”

Dr Samuel Cortese

Session of prize winners

During the J-EUNETHYDIS prize-winners’ session, introduced by Dr Samuel Cortese (Psychology Department, University of Southampton, UK), the contributions of emerging researchers in the field of ADHD were highlighted.

The first winning abstract was presented by Ebba Du Rietz (Department of Social, Genetic and Development Psychiatry, King’s College London, UK) and shared data from her PhD project showing evidence for association between polygenic risk for ADHD and related traits, cognitive impairments and frequently co-occurring disorders.8

The second winning abstract was presented by Martine Hoogman (Radboud University Medical Center, Nijmegen, The Netherlands), who discussed her research showing a clear difference in the thickness of several brain areas in patients with ADHD versus controls,9 with a particular difference seen in childhood.

Following these well-received presentations, the ECAP-ADHD Paper of the Year Award 2015 was awarded to Hanneke van Ewijk (Vrije Universiteit Amsterdam, Clinical Neuropsychology section, Amsterdam, The Netherlands) and the Kramer-Pollnow Young Investigator Award 2016 was awarded to joint winners, Corina Greven (Radboud University Medical Center and Karakter Child and Adolescent Psychiatry University Center, Nijmegen, Amsterdam, The Netherlands and King’s College London, UK) and Chia-Fen Hsu (Institute for Disorders of Impulse and Attention, Developmental Brain-Behaviour Laboratory, University of Southampton, UK).

Dr Cortese: “I think this awards session highlights how well EUNETHYDIS nurtures the emerging talent in the field of ADHD.”

Professor Rosemary Tannock



Professor Eric Taylor



Debate

Research Domain Criteria (RDoC) represent a major progression in scientific research and clinical practice in ADHD

In the final session of the conference, Professor Rosemary Tannock (Department of Child and Adolescent Psychiatry, King’s College London, UK) argued the motion that Research Domain Criteria (RDoC) represent a major progression for scientific research and clinical practice in ADHD. Professor Tannock began the debate with a brief overview of RDoC, describing it as a new framework for research, aiming to create a new taxonomy for mental disorders focusing on genetics, neuroscience and behavioural science. Professor Tannock began by arguing that the DSM criteria are too simplistic for our current understanding of ADHD, and that RDoC are better able to consider the heterogeneity of ADHD and factors including comorbidity as well as environmental and developmental influences.

Professor Eric Taylor (Department of Child and Adolescent Psychiatry, King’s College London, UK) then passionately argued that RDoC threaten to divorce research from clinical practice and could even lead to the loss of ADHD as a clinical concept. Professor Taylor went on to conclude that there is a risk of beginning to treat the neural circuit rather than the patient.

At the end of the debate the audience were divided, with the overall consensus being that a compromise is needed between the past and future. Elements of RDoC were noted as being required to increase our understanding of ADHD, but there is still a place for the more traditional research methods.

Professor Tannock: “The ICD and DSM have provided useful tools…but we are so limited in knowing for the patient in front of us, what is the optimised treatment pathway.”

Professor Taylor: “It is speculative, not evidence-based, assumes independence of processes, ignores social influences and reflects current US science politics.”

  1. Tripp G. Reward, punishment and ADHD: an overview of behavioural effects and brain mechanisms. Abstract from 4th EUNETHYDIS International Conference on ADHD. 2016; 50.
  2. Furukawa E, Alsop B, Sowerby P, et al. Evidence for increased behavioral control by punishment in children with attention-deficit hyperactivity disorder. J Child Psychol Psychiatry 2016; Epub ahead of print.
  3. Groom MJ. Effects of arousal and motivation on brain and behaviour in ADHD. Abstract from 4th EUNETHYDIS International Conference on ADHD. 2016; 48.
  4. Sobanski E, Banaschewski T, Asherson P, et al. Emotional lability in children and adolescents with attention deficit/hyperactivity disorder (ADHD): clinical correlates and familial prevalence. J Child Psychol Psychiatry 2010; 51: 915-923.
  5. Storebø OJ, Krogh HB, Ramstad E, et al. Methylphenidate for attention-deficit/hyperactivity disorder in children and adolescents: Cochrane systematic review with meta-analyses and trial sequential analyses of randomised clinical trials. BMJ 2015; 351: h5203.
  6. Sibley MH, Swanson JM, Arnold LE, et al. Defining ADHD symptom persistence in adulthood: optimizing sensitivity and specificity. J Child Psychol Psychiatry 2016; Epub ahead of print.
  7. Hechtman L, Swanson JM, Sibley MH, et al. Functional adult outcomes 16 years after childhood diagnosis of attention-deficit/hyperactivity disorder: MTA results. J Am Acad Child Adolesc Psychiatry 2016; 55: 945-952.
  8. Du Rietz E. Association between polygenic risk for ADHD and related traits, cognitive impairments and frequently co-occurring disorders. Abstract from 4th EUNETHYDIS International Conference on ADHD. 2016; 80.
  9. Hoogman M. A large scaled study of cortical measures in ADHD across the life span: an ENIGMA-ADHD collaboration. Abstract from 4th EUNETHYDIS International Conference on ADHD. 2016; 81.