Comparison in symptoms between aged and younger patients with narcolepsy

We investigated the age-related changes in symptoms in narcolepsy. Fifty patients, 65-year-old and over (aged group), were recruited from the National Narcolepsy Registry. Thirty-four patients, younger than 65 (younger group), were selected by random sampling. Although there was no difference in the age of disease onset between the two groups, the age of diagnosis was significantly earlier for the younger group. Methylphenidate was used significantly more in the aged group, and modafinil in the younger group. The aged group had lower total scores on the Ullanlinna Narcolepsy Scale, because the scores for cataplexy were significantly less for the aged group. There was no significant difference in excessive daytime sleepiness between the two groups.

The development of selective attention in children with attention deficit hyperactivity disorder

The influence of age on a selective attention task was studied in a sample of children with and without Attention Deficit Hyperactivity Disorder (ADHD). The impact of methylphenidate (MPH) treatment on selective attention was also investigated in the children with ADHD. Two age groups of children with ADHD and two age groups of control children were tested using a timed computer task. The task consisted of identifying visual target stimuli under various distracter conditions. Distracters varied on the basis of modality (i.e., visual, auditory, or both) and task relevance (i.e., meaningful or irrelevant). Reaction times and accuracy were measured. Children with ADHD were less efficient on the selective attention task than were children without ADHD, and older children were more efficient than younger children in both groups. Children without ADHD were influenced more by the nature of distracters than were children with ADHD. For children with ADHD, MPH improved performance overall.

Toward individualized evidence-based medicine: five "N of 1" trials of methylphenidate in geriatric patients

OBJECTIVES

To investigate the efficacy of methylphenidate in depressed or apathetic geriatric patients.

DESIGN

Five "N of 1" trials (individual cross-over, double-blinded, randomized trials).

SETTING

Department of Geriatrics, University Medical Center, Nijmegen, and two nursing homes in Nijmegen, the Netherlands.

PARTICIPANTS

Patients suffered from depression due to a general medical condition (n = 2); depression resistant to antidepressive drugs (n = 1), chronic apathy due to mild and moderate severe dementia (n = 2).

INTERVENTION

Methylphenidate (5 mg bid) and placebo (both for two subsequent days) in 5 weeks of randomized treatment blocks.

MEASUREMENTS

Montgomery Asberg Depression Rating Scale (MADRS), Apathy Evaluation Scale (AES)-clinician, the AES-informant, Barthel index and a semiquantitative checklist of adverse effects.

RESULTS

Among the three depressed patients, two showed significant improvement on the MADRS (P = .089 and P = .001; alpha = 0.10), one patient's apathy showed significant improvement on AES-clinician and -informant (P = .077 and P = .086). One apathetic patient's trial was stopped because AES could not be completed. None of the patients showed significant changes in the Barthel index. No side effects developed.

CONCLUSION

"N of 1" trials are useful in evaluating efficacy of methylphenidate in depressed or apathetic geriatric patients. Single-patient trials can be a useful tool in pharmacotherapeutic decision-making in frail older subjects.

Dose-response effects of methylphenidate on ecologically valid measures of academic performance and classroom behavior in adolescents with ADHD

The effects of methylphenidate on the academic performance and classroom behavior of 45 adolescents with attention deficit hyperactivity disorder were studied. During a 6-week, placebo-controlled medication assessment in the context of a summer treatment program, participants received a double-blind, crossover trial of 3 doses of methylphenidate. Dependent measures included note-taking quality, quiz and worksheet scores, written language usage and productivity, teacher ratings, on-task and disruptive behavior, and homework completion. Group data showed positive effects of methylphenidate on academic measures; however, the greatest benefit came with the lowest dose. Although additional benefit did occur for some participants with higher doses, the largest increment of change usually occurred between the placebo and 10-mg dose. Many adolescents did not experience added benefit with increased dosages, and in some cases they experienced deterioration. Guidelines for assessment of medication effects are discussed.

Methylphenidate for fatigue in advanced cancer: a prospective open-label pilot study

Psychostimulants such as methylphenidate are used for fatigue in cancer patients. We report a prospective, open-label, pilot study of the successful use of methylphenidate to treat fatigue in nine of 11 consecutive patients with advanced cancer. Seven had received radiation or chemotherapy, a median of three weeks (range from one to 30 weeks) prior to methylphenidate. A rapid onset of benefit was noted, even in the presence of mild anemia. Sedation and pain also improved in some. Only one patient had side effects severe enough to stop the medication.

[Neuropsychological follow-up of attention deficit/hyperactive disorder in adulthood before and after treatment with methylphenidate]

Attention-deficit/hyperactivity disorder (ADHD) in adulthood is frequently overlooked. Motor restlessness, impulsivity, low frustration tolerance, and conduct disorders are diagnostically ambiguous, but are predominantly ascribed to affective disorders, anxiety disorders, and personality disorders. Furthermore, substance-induced addiction may develop consecutively to untreated ADHD. We report on a case of primary diagnosis of ADHD in adulthood with secondary cocaine dependency, who was neuropsychologically assessed before and following treatment with methylphenidate. Frequency of errors and reaction time in performance on attention tests, concentration tasks, and multiple stimuli-/reaction tasks improved under treatment with methylphenidate. ADHD may be treated efficiently even after primary diagnosis in adulthood. Differential diagnosis of ADHD should be considered in disorders associated with motor hyperactivity, impulsivity, stress intolerance and conduct disorders.

An auditable protocol for treating attention deficit/hyperactivity disorder

We present an auditable protocol for attention deficit/hyperactivity disorder (ADHD) or hyperkinetic disorder. The protocol is derived from standard recommendations and evidence, and is intended for outpatient medical clinic practice in secondary care. Suggested side effect rating scales are included.

Fatigue in multiple sclerosis

Fatigue is among the most common, yet least understood, symptoms of multiple sclerosis (MS) [1.]. It can profoundly disrupt the occupational and social functioning of patients, and is recognized as a criterion for MS disability by the Social Security Administration. Most approaches to fatigue assessment can be classified as either self-report scales or performance-based measures of motor or cognitive output. During the clinical management of fatigue, it is important to consider the role of other MS symptoms on fatigue, as well as that of non-MS-related medical conditions. Management of fatigue in MS often entails both pharmacologic and behavioral components. This article reviews recent developments in the assessment, treatment, and pathogenesis of MS fatigue.

Short-term cardiovascular effects of methylphenidate and adderall

OBJECTIVE

The primary purpose of this study was to examine the cardiovascular effects of Adderall (ADL) in a clinic-based group of youths with attention-deficit/hyperactivity disorder ranging in age from 4 to 17 years.

METHOD

One hundred thirty-seven patients were treated with either methylphenidate (MPH) or ADL. Youths prescribed MPH were given medication twice daily, and youths treated with ADL received medication once daily. Patients were evaluated under five conditions: baseline, placebo, 5 mg/dose, 10 mg/dose, or 15 mg/dose. Resting pulse, diastolic blood pressure, and systolic blood pressure were examined after 1 week at each treatment condition. Changes from baseline on these parameters were examined.

RESULTS

The short-term cardiovascular effects of both ADL and MPH were modest. No patients experienced any clinically significant change in these cardiovascular measures during the course of this brief trial.

CONCLUSION

Since the short-term cardiovascular effects of ADL appear minimal, specific cardiovascular monitoring during short-term ADL treatment at doses of 15 mg/day or less does not appear to be indicated. In addition, under similar conditions, using similar methods, both medication treatments led to changes in blood pressure and pulse that were clinically insignificant.

Psychostimulants in preschool children with attention-deficit/hyperactivity disorder: clinical evidence from a developmental disorders institution

OBJECTIVE

To examine psychostimulant response in preschool children with attention-deficit/hyperactivity disorder (ADHD) in an outpatient child psychiatry clinic (housed within a developmental disorders institution) over 3, 12, and 24 months of treatment.

METHOD

A systematic retrospective chart review was conducted for 27 preschool children with ADHD who were started on psychostimulants between the ages of 3 and 5 years, inclusive. Two child and adolescent psychiatrists reviewed each chart independently, using the Clinical Global Impressions (CGI) scale to rate the severity of illness and global improvement and the Side Effects Rating Form to rate side effects.

RESULTS

Over 24 months, psychostimulants were stopped in three children (11%) because of side effects and concomitant psychotropic medications were added in seven children (26%). The CGI severity-of-illness ratings showed a significant effect of time over 3, 12, and 24 months of psychostimulant treatment (all p values < .0001). Rate of response was 74% at 3 months and 70% at 12 and 24 months. Side effects were mostly mild and occurred in 63% of the children at 3 months, 41% at 12 months, and 29% at 24 months.

CONCLUSIONS

The findings suggest that preschool children with developmental disorders respond to psychostimulants but need close monitoring because of frequent side effects. Inasmuch as the study participants were recruited from a child psychiatry clinic housed within a developmental disorders institution and had a high rate of developmental disorders, the findings may not generalize to other preschool children with ADHD.

Amelioration of specific working memory deficits by methylphenidate in a case of adult attention deficit/hyperactivity disorder

Cognitive neuroscience has provided an extensive literature on the neuroanatomy and psychopharmacology of working memory. However, while it has been shown that children with attention deficit/hyperactivity disorder (AD/HD) have deficits in working memory, relatively little is known about working memory functions in adults diagnosed with AD/HD. Furthermore, it remains to be seen whether methylphenidate (Ritalin), which is used in the treatment of childhood AD/HD can improve performance deficits in adult AD/HD patients. We have used three paradigms of spatial working memory validated in cortical lesion patients, and psychopharmacological and neuroimaging studies, in order to examine the effects of methylphenidate administration in a case of an adult diagnosed with AD/HD. In the AD/HD patient at baseline testing, performance on a test of spatial recognition memory and on a task of self-ordered spatial working memory was shown to be impaired. Importantly, the impairments on the self-ordered spatial working memory task were ameliorated by an acute oral dose of methylphenidate (0.5 mg/kg). These findings provide insights into the possible neurochemical and neuroanatomical substrates of the action of methylphenidate in AD/HD and suggest a useful methodology for further research into this potentially debilitating disorder.

Present and future pharmacotherapeutic options for adult attention deficit/hyperactivity disorder

Attention deficit/hyperactivity disorder (ADHD) is often a lifelong condition. When untreated or undertreated, it appears to have a deleterious impact upon the daily functioning of the majority of adults that were diagnosed with this condition during childhood. Effective treatment, under the best circumstances, is multi-modal. The recent MTA study staged by the United States government confirmed the primary role of psychostimulants for children with this condition. The findings from this study have been generalised to adults that also have ADHD, particularly in cases where there is a well-defined longitudinal history dating back to early childhood. Psychostimulants remain a viable first-choice strategy for adults with ADHD. There are idiosyncratic differences in response to the various psychostimulants for any given individual with ADHD. Furthermore, the emergence of long-acting, once daily psychostimulant medications is likely to improve the calibre of care for adults with ADHD. A number of alternative pharmacotherapies have been studied, or are being developed, for adults with ADHD. These pharmacotherapies include antidepressant medications that affect dopaminergic and noradrenergic bioavailability, as well as cholinergic agents. In addition, agents that manipulate histaminergic and glutaminergic receptors are being studied as possible non-stimulant alternatives in the management of adult ADHD. More information is needed before any definitive statements can be made concerning the feasibility and utility of these non-stimulant medication approaches.

A four-fold model for subgrouping the hyperkinetic/MBD syndrome

The major finding of this study is that the presence or absence of aggressive symptomatology differentiates a group of 84 six to twelve year-old Hyperkinetic/MBD boys on a number of important measures at initial referral, during treatment with methylphenidate, and at subsequent five-year-follow-up. When the sample is sorted into high and low aggression groups, several findings emerge which would otherwise have been obscured. Furthermore, there are no significant interactions between aggression (control deficits, negative affect, aggressive interpersonal behavior) and hypertactivity (judgment deficits, hyperactivity, inattention). The value of differentiating between exclusive hyperactivity with aggression) is indicated by the present study.

Urinary phenylacetate and response to methylphenidate

Phenylacetate (PAA) is the metabolic end-product of phenylalanine, a catecholamine precursor, and of phenylethylamine, a centrally active neurochemical substance which has been implicated in the actions of stimulant medications. PAA has been reported to be low in unipolar depression. We measured 24-h urinary PAA in normal controls (N = 21) and in-patients with unipolar depression (N = 33; 12 drug-free) and did subsequent dexamethasome suppression tests (DST). We also gave patients methylphenidate challenges, examining mood response. There were no significant differences between depressed patients and controls in 24-h urinary PAA excretion (P greater than 0.9). However, the variance in PAA excretion was higher in patients than normals and 5 patients had values at or above the 99% confidence limits for the normal control group. There was no association of DST results with PAA excretion (P greater than 0.4). Patients with a worsened mood after taking methylphenidate excreted less PAA than those with an improved mood, however (P less than 0.025). The clinical and theoretical significance of these results is discussed.

Stimulant treatment in young boys with symptoms suggesting childhood mania: a report from a longitudinal study

This study used data from a completed longitudinal study to examine the effects of methylphenidate on 6-12-year-old boys presumably at risk for bipolar disorder. Of 75 boys referred, diagnosed with hyperkinetic reaction of childhood (minimal brain dysfunction), treated clinically with methylphenidate, and followed as young adults, 23% (the maximorbid or MAX group) had childhood symptoms of irritability and emulated DSM-IV diagnoses of attention deficit hyperactivity disorder (ADHD), plus oppositional defiant or conduct disorder (ODD/CD) and anxiety or depression or both. The remaining boys (the minimorbid or MIN group) had fewer symptoms and disorders. MAX and MIN groups did not differ in rated response to methylphenidate, duration of treatment, clinically determined maintenance doses, concurrent or subsequent treatment with other medications, or other aspects of medication experience. At ages 21-23, individuals with bipolar-related lifetime diagnoses (adult mania, hypomania, or cyclothymia) did not differ from those without bipolar-related diagnoses in any aspect of early methylphenidate treatment history. These findings indicate that ADHD boys with symptoms suggesting childhood mania do not respond differently to methylphenidate than boys without such symptoms, and there is no evidence here that methylphenidate precipitates young adult bipolar disorders in susceptible individuals.

Psychosocial treatment issues in the MTA: a reply to Greene and Ablon

Discussed several of Greene and Ablon's (this issue) key points in their article about the Multimodal Treatment Study (MTA) of Children with Attention Deficit Hyperactivity Disorder (ADHD). In particular, the following issues are addressed: (a) whether the medication management and behavioral arms of the MTA individualized treatment to comparable degrees; (b) whether cognitive-behavioral interventions were incorporated to an adequate extent; (c) whether core ADHD symptoms were overemphasized relative to other functional domains, both as treatment targets and outcome measures; and (d) whether parent and teacher characteristics warranted more emphasis than they were given. These issues are discussed and an attempt is made to fit the MTA findings into the larger context of prior studies on treatment of childhood ADHD. A theme of this commentary is the concern that in the current age of biological emphasis in the field of ADHD research, social, family, and motivational processes may not get the attention they deserve.

Stimulant effects in attention deficit hyperactivity disorder: theoretical and empirical issues

The explanatory utility of a theory or model of ADHD or any disorder depends fundamentally on its capacity to address issues of causality. What causes a particular child to develop ADHD? What mechanisms are responsible for temporal and setting-related variations in symptom severity, and how are these mechanisms affected by pharmacological intervention? And, what processes determine whether gains in one domain will propagate across one or more others? It should be evident from the foregoing discussion that comprehensive answers to such questions are most likely to emerge through implementation of research strategies that (a) integrate biological and psychological levels of explanation, (b) permit analysis of causal hypotheses, and (c) address mechanisms involved in both etiology and mediation of treatment response. Although extant neurobiological studies of ADHD are as compelling as they are exciting, they are limited by a troubling reductionistic emphasis. The predominant animal models focus on a narrow range of behaviors that are presumed to be central to ADHD because of the topographic similarity they bear to those represented by the diagnostic criteria incorporated into the diagnostic nomenclature. These models would become increasingly valuable to the extent that future research examined the extent to which ecologically relevant behaviors (e.g., social behavior) are compromised in the animal strains and whether the observed compromises are parallel to the correlates of ADHD observed in humans. Similarly, human molecular genetic studies have provided a glimpse into the possible role that genes related to dopaminergic neurotransmission may play in the etiology of ADHD. Yet, the features of ADHD have been conceptualized in these investigations as a unitary collection of characteristics, and this has precluded analysis of what specific syndromal feature (if any single one) is affected by the implicated genes. It is intriguing to speculate whether varying combinations of genes governing properties of DA receptors and reuptake molecules are associated with different patterns of symptom severity or responses to stimulant medications. As testing procedures for determining genotypes with respect to these features become more affordable and available, it should become increasingly feasible to examine such issues empirically. Research on the utility of stimulant drugs as a treatment for ADHD also has yielded useful information. Although the effects of MPH are of short duration, the breadth of their impact is impressive. The clinical effectiveness of these medications is no longer in doubt, and patterns of relations among outcome measures represent a potentially fruitful target of scientific inquiry. Finally, data supporting a neurobiological substrate for ADHD, evidence indicating that task and setting variables moderate the expression of the syndrome's diagnostic features (see Barkley, 1998, for a review), and the causal emphasis of the conceptual model with which the discussion began collectively argue for a diathesis-stress conception of the syndrome. And, as foregoing comments make clear, task and setting variables and the mechanisms through which they influence symptom expression are as important to the phenomenon as are neurobiological predisposing causes. This has significant implications for assessment strategies employed in diagnosis and evaluation of treatment-outcome. Specifically, it suggests that theory-based experimental manipulations of task and setting variables designed to impose challenge on hypothesized core features of the disorder are more likely to yield insights into the causal mechanisms governing behavioral organization in affected children than strategies emphasizing static identification of diagnostic correlates. It is hoped that such an approach will accelerate the discovery of increasingly effective assessment and intervention strategies.

Comprehensive versus matched psychosocial treatment in the MTA study: conceptual and empirical issues

Addressed some factual inaccuracies and presented alternative positions on key issues raised in the article by Greene and Ablon (this issue) on the question, "What does the Multimodal Treatment Study (MTA) tell us about effective psychosocial treatment for attention deficit hyperactivity disorder (ADHD)?" The Greene and Ablon critique does not present for the reader's consideration the full range of findings from the MTA study, notably those most relevant to psychosocial treatment, and articulates a theoretical position that effective treatment requires matching treatment to children's assessed needs, an approach not taken in the MTA study. In this article, I present the full range of findings from the MTA study related to psychosocial treatment effects, correct the misperceptions that exist about the study based on limited reviews such as Greene and Ablon's, and review the empirical and experimental design issues that produced the decision by the MTA investigative team to study the effects of intensive, comprehensive psychosocial treatment. I argue that the questions asked by the MTA study about psychosocial treatment were important, relevant, and were addressed well in the MTA study design.

Tailored psychosocial treatments for ADHD: the search for a good fit

Commented on the article "What Does the MTA Study Tell Us About Effective Psychosocial Treatment for ADHD?" by Greene and Ablon (this issue). In this article, these authors note that the Multimodal Treatment Study (MTA) did not focus on or provide information about how to match treatment to the needs of the individual child. They contend that cognitive-behavioral treatment (CBT), which was not included in the MTA, can facilitate treatment tailoring if delivered appropriately. The authors offer several suggestions regarding how CBT can be structured to meet the needs of each child. This commentary points out that the MTA included psychosocial treatments with established rather than potential efficacy. Systematic studies are needed to determine whether the suggestions offered by Greene and Ablon have clinical utility. Matching treatment to the needs of individual patients remains the overarching goal of those interested in idiographic approaches to treatment. However, efforts to inform on treatment tailoring involve complex design and needs assessment methodologies. Several suggestions are offered regarding the technology of treatment tailoring. These include the use of goal attainment scaling to identify and evaluate individualized outcome measures and the use of hybrid efficacy-effectiveness designs to assess the impact of treatment preference on outcome.

ADHD treatment in the 21st century: pushing the envelope

Required for optimal intervention for attention deficit hyperactivity disorder (ADHD) is evidence-based matching of child, treatment, and situation. The landmark Multimodal Treatment Study (MTA) of Children with ADHD documented the superiority of pharmacotherapy for the vast majority of children with ADHD. Although this study could not address the problem of the match directly, it is generating important leads for research on the use of psychosocial strategies to enhance the scope and durability of treatment gains while decreasing the risks attendant upon long-term use of medication. Given the inherent distinctions between pharmacological and psychosocial treatments, conclusive answers to questions about comparative efficacy will continue to elude scientist-practitioners. Needed next is research examining ways to improve outcomes beyond the effects of medication, using systematically tailored and sequenced psychosocial approaches and exploring new treatment targets, agents, and modalities. To illustrate, some emerging findings from an ongoing experience sampling study and implications for online therapy are discussed.

What does the MTA study tell us about effective psychosocial treatment for ADHD?

Discussed the initial findings from the recently published, National Institute of Mental Health-sponsored Multimodal Treatment Study (MTA) of attention deficit hyperactivity disorder (ADHD). These findings can be summarized as follows: Medical management alone was found to be significantly more effective for the core symptoms of ADHD as compared to behavioral treatment alone and routine (community) care, and behavioral treatment did not significantly improve outcome when combined with medical treatment. In discussing these findings, it is important to be explicit about the research questions the study was and was not designed to answer. The MTA study provided useful information regarding the question, "Does a very intensive form of behavioral treatment deliver greater benefits than the less intensive forms of behavioral treatment investigated in prior studies?" but little insight on the question, "What type of treatment by what type of therapist is most effective in dealing with what specific problems among specific children with ADHD?" It is suggested that the clearest finding from the MTA study is that the effectiveness of psychosocial intervention for ADHD hinges on the degree to which a broad range of treatment ingredients are considered, carefully selected, matched, and tailored to the individual needs of each child with the disorder, and implemented and monitored over the long term.