الفهرس 
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Abstract
Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder of childhood. It affects approximately 4% of all children, although estimates vary widely from 3% to 11% or more. According to The Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) it is characterized by symptoms of inattention and/or impulsivity and hyperactivity. ADHD appears to be associated with a wide variety of other psychiatric problems, which are often co-morbid with it, far more often than it appears alone. The goal of ADHD treatment is to improve symptoms, optimize functional performance, and remove behav¬ioral obstacles. Treatment consists of a variety of approaches including family and parenting support, educational accommodations, behavioral therapy, and medication. Recommendations for treatment vary according to the patient age. The objective of the current work was to study and compare the efficacy of different intervention combinations on the core symptoms of ADHD and its co-morbidities (with special emphasis on conduct problem, academic performance, and peer relationship).
The current study was conducted on 60 school aged children (range from 6-10 years), with the diagnosis of ADHD according to DSM-5 criteria, children were recruited from Alexandria University Children’s Hospital (AUCH) and some specialized private clinics and they were allocated to different interventional strategies of treatment including (pharmacological, atomoxetine only for 3 month duration n=15) or in combination with (24 OST sessions n=15), (6 sessions of BPT n=15) or (24 sessions NFT n=15). All studied children had undergone pre and post interventional assessment with Arabic form of Conners’ Parent Rating Scale short form (CPRS-48) and formal interview with both child and parent(s).
There was homogenous distribution of the studied children among the four groups regarding demographic data (age, sex), total IQ scores, family history, and predominant presentation. Disruptive behavioral disorders (ODD and CD) were the most common co-morbidities among the four studied groups. There was no significant difference regarding side effects of atomoxetine among the four groups.
According to the pre and post assessment scores of CPRS-48, the study revealed significant reduction regarding hyperactivity/impulsivity and conduct problem among both groups (OST +MED) (P=0.010, P= 0.027 respectively) and group (BPT+MED) (P < 0.001, P < 0.001 respectively) while significant decrease in the scores regarding inattention was found only among group (BPT+MED) (P <0.001). However significant reduction of learning problem scores was shown among group (BPT+MED) (P <0.001) and group (NFT+MED) (P=0.007).
Based of parental interview assessment pre and post interventions, significant improvement of academic performance and peer relationship was shown among both groups (OST+MED) (P=0.020, P= 0.021 respectively) and group (BPT +MED) (P= 0.020, P= 0.001 respectively). Regarding group (NFT+MED) neurofeedback assessment pre, mid, and post sessions showed no significant electrophysiological difference except for significant increase in the mean amplitude of trained Beta 1(15-20 Hz) (P=0.035) between pre and post NF assessment.
Comparison of the four studied groups, according to percentage change of CPRS-48 scores pre and post intervention, showed that group (BPT +MED) was superior to the other 3 groups regarding ADHD core symptoms and all its co-morbidities. However, this superiority was statistically significant regarding conduct problem (P <0.001), inattention (P=0.040), and peer relationship (P=0.001). Moreover, the three studied combination interventional groups (OST, BPT, and NFT) showed superior difference in the percentage of change of CPRS-48 in comparison to group MED only.
The current study concluded that, combined (BPT +MED) is significantly effective interventional modality in treatment of ADHD core symptoms and its co-morbidities including; conduct problem, academic performance and peer relationship. Combined OST+MED had significant efficacy on hyperactivity/impulsivity, co-morbid conduct problem, academic and peer relationship. However group NFT+MED was significantly effective only on learning problem. Finally group MED only showed no significant efficacy on either ADHD core symptoms or its co-morbidities. Moreover, multi-component interventions had superior efficacy than medication only on both ADHD core symptoms and its co-morbidities.
Recommendations of the study include; 1) Implementation of behavioral parent training program in the routine care management of school age children with ADHD; 2) Encouragement of the use of multimodal interventional strategies, especially those evidenced based, in the treatment of ADHD in children; 3) Individualization of the management plan for each child with ADHD according to his/her functional impairment with adequate management of any co-morbid behavioral or psychiatric disorders;
4) Implementation and further research on neurofeedback training, as a promising therapy, in the treatment of ADHD in children.