The adolescent outcome of hyperactive children diagnosed by research criteria: I. An 8-year prospective follow-up study

Neurobehavioural deficits associated with apoptotic neurodegeneration and vulnerability for ADHD

Several studies involving postnatal administration of the N-methyl-D-aspartate (NMDA) antagonists, dizocilpine (MK-801; 3 x 0.5 mg/kg, at 08.00, 16.00 and 24.00 h) on Postnatal day 11, or Ketamine (1 x 50 mg/kg) or Ethanol (1 x 2.5 g/kg, Ethanol-Low, or 2 x 2.5 g/kg, 2-h interval, Ethanol-High) on Postnatal day 10, are described. Some mice from each treatment/vehicle group were sacrificed 24 h after NMDA antagonist treatment and brain regions were taken for fluoro-jade staining analysis. Functional analysis was initiated at 60 days of age. All three treatments inducing an antagonistic action at NMDA receptors, MK-801, Ketamine and Ethanol-High induced a similar pattern of initial hypoactivity followed by marked and lasting hyperactivity in the motor activity test chambers. In each case, the basal hyperactivity level was abolished by acute treatment with a low dose of D-amphetamine (0.25 mg/kg). All three treatments, MK-801, Ketamine and Ethanol-High, induced a deficit in acquisitive performance in the radial arm maze test of instrumental learning. The deficit induced by postnatal MK-801 was abolished by acute treatment with the low dose of D-amphetamine. All three treatments, MK-801, Ketamine and Ethanol-High, resulted in normal acquisitive performance during the first three test days in the circular swim with the submerged platform maintained in a constant position, but on the fourth test day, with the platform position shifted to a different "quadrant", induced marked deficits. Fluoro-jade staining analyses indicated a devastating cell degeneration in several brain regions of mice administered NMDA antagonists postnatally, including the hippocampus, frontal cortex, parietal cortex, and cerebellum. Severe cell degeneration in the laterodorsal thalamus due to Ethanol or diazepam (5 mg/kg) appeared not to affect the different aspects of function. The pattern of dysfunctional outcome and apoptotic cell loss following postnatal NMDA antagonist treatment offers a plausible similarity to the major aspects of 'syndromatic continuity' in ADHD, hyperactivity, inattention and impulsivity, thereby providing an interesting animal model of the disorder.

Childhood ADHD and adolescent substance use: an examination of deviant peer group affiliation as a risk factor

Deviant peer group affiliation was evaluated as a risk factor for substance use in adolescents with childhood attention-deficit/hyperactivity disorder (ADHD). Results showed that deviant peer affiliation mediated the relationship between ADHD and substance use, suggesting that children with ADHD are more likely than children without ADHD to become involved with deviant peers and, as a result, more likely to use substances. Moreover, the relationship between deviant peer affiliation and substance use was stronger for adolescents with ADHD, suggesting that once they are immersed in a deviant peer group, adolescents with ADHD are more vulnerable to the negative social influences of that group. This study is the first step in identifying high-risk pathways from childhood ADHD to substance use in adolescence.

Attention-deficit/hyperactivity disorder: increased costs for patients and their families

OBJECTIVE

To estimate the direct (medical and prescription drug) and indirect (work loss) costs of children treated for attention-deficit/hyperactivity disorder (ADHD) and their family members.

METHOD

The data source was an administrative database from a national, Fortune 100 manufacturer that included all medical, pharmaceutical, and disability claims for beneficiaries (n > 100,000). The analysis involved four samples. The ADHD patient sample included individuals age 18 or younger with at least one ADHD claim during the study period (1996-1998). Resource utilization of ADHD patients was contrasted with a matched control sample of patients who did not have claims for ADHD. The ADHD and non-ADHD family samples included non-ADHD family members of ADHD patients and their matched controls.

RESULTS

The annual average expenditure (direct cost) per ADHD patient was $1,574, compared to $541 among matched controls. The annual average payment (direct plus indirect cost) per family member was $2,728 for non-ADHD family members of ADHD patients versus $1,440 for family members of matched controls. Both patient and family cost differences were significant at the 95% confidence level.

CONCLUSIONS

ADHD imposes a significant financial burden regarding the cost of medical care and work loss for patients and family members.

Personality differences associated with smoking experimentation among adolescents with and without comorbid symptoms of ADHD

This study evaluated differences in adolescent personality (novelty seeking, harm avoidance, and reward dependence), lifetime cigarette smoking, and symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD) among 1051 youths enrolled in several public high schools in middle Atlantic towns in the United States in 2000 and 2001. Psychological and behavioral data were obtained via self-report on the Temperament and Character Inventory (personality), standard epidemiological survey items (smoking), and the Current Symptoms Scale (ADHD). The results indicated that adolescent "ever smokers" with high-normal symptoms of ADHD had the highest novelty seeking scores compared to all other study groups. These data highlight the greater "vulnerability" to smoking that is associated with novelty seeking and symptoms of inattention and hyperactivity. To the extent that novelty seeking and ADHD share cognitive and/or behavioral elements that may negatively impact upon youths' ability to attend to tobacco control communications, additional research on ways to adjust the delivery and content of smoking prevention and intervention program messages to meet the needs of these adolescents is warranted.

Transtornos do déficit de atenção com hiperatividade: aspectos neurológicos

Transtorno do Déficit de Atenção com Hiperatividade, caracterizado por pobre atenção sustentada, diminuição do controle dos impulsos e excessiva atividade física, é encontrada em muitas culturas e em muitos países. O objetivo do presente artigo é revisar a literatura publicada sob o assunto, com ênfase nos aspectos neuropsicológicos. As conclusões encontradas são que a farmacoterapia em conjunção com terapia individual ou familiar são, geralmente, aceitos como os mais efetivos tratamentos, sendo os psicoestimulantes as drogas de escolha. A indicação de psicoterapia é discutida. A necessidade de cuidadoso diagnóstico e condução médica e psicológica é enfatizada.

Persistence of Attention-Deficit/Hyperactivity Disorder into adulthood: what have we learned from the prospective follow-up studies?

OBJECTIVES

Longitudinal studies of children with Attention-Deficit/Hyperactivity Disorder (ADHD) into adolescence have all reported high rates of ADHD. However, findings from studies into adulthood are inconsistent. This article reviews factors that may account for disparate rates found in adult follow-ups, and recommends optimal methodologies for prospective studies of children with ADHD in particular and childhood mental disorders in general.

METHOD

Follow-up studies of children with ADHD into adulthood are critically reviewed to identify factors that influence adult ADHD prevalence estimates.

RESULTS

Four factors are identified: (1) ascertainment procedure, (2) attrition rate, (3) reporting source, and (4) disorder criteria.

CONCLUSIONS

Estimates of the proportion of children with ADHD who will experience symptoms of the childhood syndrome in adulthood are likely to vary considerably, as a function of multiple factors. Several recommendations are made for designing future follow-up investigations.

Child and familial pathways to academic achievement and behavioral adjustment: a prospective six-year study of children with and without ADHD

This longitudinal study examined familial and child predictors of academic achievement and behavioral adjustment. Participants included 115 children with ADHD and 59 normative comparisons. Data analyses spanned three assessment waves from elementary- through secondary-school grades. We evaluated the degree to which child and familial factors present during middle school mediated relationships between childhood ADHD, subsequent academic achievement, and behavioral adjustment during high school. We found that emotional and behavioral well-being of ADHD children during middle school mediated relations between childhood ADHD and adverse academic and behavioral outcomes during high school. In addition, familial factors in middle school years predicted the behavioral adjustment of children in both the ADHD and non-ADHD groups. Academic achievement during high school was strongly associated with previous achievement levels. Our results provide support for tailoring preventive interventions to the unique needs of children with ADHD and their parents at various stages of adolescent development.

The wide attentional window: a major deficit of children with attention difficulties

The present study assessed visual selective attention in children with attention difficulties compared to age-matched, typically achieving children. We used the flanker task, which requires participants to respond to a central target flanked by distractors, and the feature and conjunction visual search, which requires participants to search for a predesignated target embedded among a variable number of distractors. The results showed that children with attention difficulties encountered major problems only when responding to a central target flanked by adjacent incongruent distractors and when searching for a conjunctive target in a high-density display. These results suggest that children with attention difficulties have a characteristic inability to restrict visual attention to a limited spatial area so as to selectively process relevant information while effectively ignoring distracting information.

Attention-deficit/hyperactivity disorder evaluation and diagnosis: a practical approach in office practice

Attention-deficit/hyperactivity disorder is the most common neurobehavioral disorder of childhood, with most children maintaining symptoms of ADHD as adolescents and as adults. It is among the most common chronic conditions that primary care pediatricians see. Progress in brain imaging, genetics, neuropsychology, and molecular biology of ADHD reveals complex interactions between neurologic mechanisms, genetics, and environmental influences. Core behaviors seen in children with ADHD include hyperactivity, impulsivity, and inattention. The DSM-IV standard for diagnosis emphasized the importance of documenting that these behaviors occur at school and in the home, the chronicity of symptoms, and the connection between the behaviors and impairments in educational achievement or social development. The complex nature of this disorder is indicated by the observation that children and adolescents with ADHD have associated conditions, such as learning disorders, anxiety, oppositional behaviors, and depression. The AAP practice guideline on the evaluation and diagnosis of school-aged children with ADHD provides primary care pediatricians with a scientific foundation for assessing children with behavior and learning problems. Attention to accurate documentation of behaviors, coexisting learning disorders and mental health conditions, and the development of office practices that support the diagnostic process will ensure that children receive an appropriate and comprehensive assessment.

Delivering more effective treatment to adolescents: Improving the juvenile drug court model

Juvenile drug courts (JDC) emerged in response to a perceived need to intervene more effectively in the substance abuse-delinquency cycle. The influx of drug and alcohol offenders, lack of other juvenile justice system interventions, and positive experiences with adult drug courts helped drive interest in adapting the drug court model for juveniles. This article: (1) provides an overview of substance use and the juvenile justice system; (2) describes the current status of JDC programs; and (3) proposes a model for planning, implementing and evaluating JDCs based on adolescent drug use and treatment research as well as current JDC models. The lack of science-based JDC models and empirically sound JDC evaluations has limited the effectiveness of JDCs. The proposed model is designed to create a new generation of JDCs that maximizes the effectiveness of local resources and delivers research-based interventions to youth and families impacted by substance abuse and delinquency.

Is attention deficit hyperactivity disorder over-represented among HIV-seronegative boys with haemophilia? Preliminary results from our centre

Haemophilia care providers report anecdotally that many boys under their care bear the diagnosis of attention deficit hyperactivity disorder (ADHD). This study investigated the hypothesis that ADHD is over-represented among boys with haemophilia. All the boys with haemophilia, aged 5-14 years, who receive their comprehensive care at our centre were solicited to participate in this study. Of the 78 eligible boys, 34 (44%) were successfully contacted and agreed to participate. All participants were HIV-negative on both serological and PCR-based assays. The presence of ADHD symptoms was established via a parent- and teacher-completed standardized rating instrument. On the parent-rating scale, 26% of the participants exceeded the cut-off for inattentive ADHD, 18% for hyperactive/impulsive ADHD, and 18% for combined. On the teacher rating scale, 4% of the participants exceeded the cut-off for inattentive ADHD, but no participants were rated as having extreme hyperactive/impulsive or combined ADHD symptoms. Retrospectively, 29% of the participants had previously been diagnosed with ADHD, all treated with stimulant medications. Of note, 38% of our participants were enrolled in special education programmes. All of the above were more common in boys with haemophilia compared with national controls. A chart review of non-participating patients from the same clinic suggested that sampling bias is unlikely to account for these differences. These results provide the first empirical evidence that ADHD may be over-represented among boys with haemophilia.

Clinical course of attention-deficit/hyperactivity disorder from childhood toward early adolescence

OBJECTIVE

To study the course of attention-deficit/hyperactivity disorder (ADHD) in late childhood to adolescence using a multi-informant and multi-assessment procedure.

METHOD

Subjects were 35 children with ADHD and 35 matched controls with a mean age of 10 years at first assessment. DSM-III-R-based structured diagnostic interviews and behavioral questionnaires based on parents, teachers, and youth informants were used. Cross-informant behavioral syndromes were obtained by use of the Child Behavior Checklist, the Teacher's Report Form, and the Youth Self-Report. Subjects were reassessed after 1.5 and 2.6 years.

RESULTS

Behavioral differences between the two groups were significant for the majority of scales for all three informants at all three times. Diagnostic interviews revealed a persistence rate of 46% over 2.6 years. However, there were only few significant behavioral differences across informants between the nonpersistent and the persistent groups. The fit between interview-derived syndrome scores reflecting subtypes of ADHD and both parents and youth questionnaire data was good, whereas for the teacher ratings it was poor. A high rate of 89% correct classification of the outcome diagnoses was possible based on behavioral data at time 1.

CONCLUSIONS

The study of the course of ADHD should be based both on interview and questionnaire data and should include several informants. Operationally defined diagnoses alone may lead to an underestimation of persistent behavioral problems.

Parenting of children with attention-defecit/hyperactivity disorder (ADHD): the role of parental ADHD symptomatology

OBJECTIVE

The present study examined the relation between parental ADHD symptomatology and parent-child behavior among 46 mothers and 26 fathers of ADHD children.

RESULTS

Fathers' self-reports of inattention and impulsivity were strongly associated with self-reports of lax parenting both before and after parent training, and with self-reports of overreactivity after parent training. Fathers' impulsivity was also associated with more arguing during audiotaped observations of parent-child interactions prior to parent training. Mothers' self-reports of inattention were modestly associated with self-reports of laxness before and after parent training. Prior to parent training, there were non-linear relations between mothers' inattention and observations of mother-child behavior, with mothers who reported moderate levels of inattention engaging in the most negative parent-child interactions. After parent training, these relations were linear, with the mothers who reported the most inattention engaging in the most negative parent-child interactions. These results were weakened but were generally still significant when parental depression and alcohol use were controlled.

Childhood predictors of adolescent substance use in a longitudinal study of children with ADHD

Children diagnosed with attention-deficit/hyperactivity disorder (ADHD; n = 142) were prospectively monitored into adolescence (13-18 years old) to evaluate their risk for elevated substance use relative to same-aged adolescents without ADHD (n = 100). Probands reported higher levels of alcohol, tobacco, and illicit drug use than did controls. Group differences were apparent for alcohol symptom scores but not for alcohol or marijuana disorder diagnoses. Within probands, severity of childhood inattention symptoms predicted multiple substance use outcomes: childhood oppositional defiant disorder/conduct disorder (ODD/CD) symptoms predicted illicit drug use and CD symptoms. Persistence of ADHD and adolescent CD were each associated with elevated substance use behaviors relative to controls. Further study of the mediating mechanisms that explain risk for early substance use and abuse in children with ADHD is warranted.

Smoking patterns and abstinence effects in smokers with no ADHD, childhood ADHD, and adult ADHD symptomatology

Cigarette smokers are known to be overrepresented among adults with Attention Deficit Hyperactivity Disorder (ADHD). To date, however, no attempt has been made to determine the extent to which a lifetime diagnosis of ADHD may be associated with smoking even in the absence of current symptomatology. We hypothesized that nicotine dependence and abstinence effects-especially effects relevant to ADHD symptomatology-would be more pronounced in adult ADHD smokers in comparison with those who reported childhood ADHD symptoms only. Results indicated that, in contrast to controls without ADHD symptomatology, both adult and childhood ADHD groups were significantly more likely to experience a number of nicotine withdrawal symptoms, including irritability and difficulty concentrating; in no instance did the ADHD groups differ from one another in this regard. Thus, studying people with childhood symptoms of ADHD, even in the absence of an adult diagnosis, may shed light on the known association between smoking and ADHD.

Attention deficit hyperactivity disorder in elementary school children in Rhode Island: associated psychosocial factors and medications used

This study was undertaken to explore psychosocial factors associated with referral for attention deficit hyperactivity disorder (ADHD) evaluation or ADHD diagnosis among elementary school children in Rhode Island, as well as to examine the extent of drug therapy among this population. A survey was distributed to parents/guardians of 2,800 3rd- to 5th-grade public school students in 4 Rhode Island school districts. The average age of the children was 9.0 +/- 1.0 years with 52% girls. Approximately 12% of the students had been referred for ADHD evaluation (RFE). Of these, 52% (6% of all children in the survey) were receiving psychoactive prescription medications daily. While the male:female ratio in the non-RFE group was almost 1:1, there were more boys than girls in the RFE group (male/female ratio of 3:1, p < 0.0001) and in the medicated group (male/female ratio 4:1, p < 0.0001). RFE children and medicated children were older than classroom peers (p < 0.0001), and had a greater degree of school misconduct (p < 0.0001). RFE children and medicated children were significantly less likely to have parents who completed college (p < 0.05), were significantly more likely to have stepparents (p < 0.05), and to be only children (p < 0.05) when compared with their peers. Amphetamine was the most commonly prescribed drug (used by 54% of the medicated children) followed by methylphenidate (43%). Nearly 18% of the medicated children were receiving 1 to 3 additional psychoactive prescription medications on a daily basis. In conclusion, RFE children and children medicated for ADHD were more likely to have a stepparent, have no siblings, and have parents that had not completed college. Amphetamine rather than methylphenidate accounted for the majority of medications used in this study, and simultaneous use of multiple psychoactive medications was reported in 18% of the medicated children.

Parental ratings of son's behavior problems in high-risk families: convergent validity, internal structure, and interparent agreement

In this research, we examined the convergent validity, internal structure, and interparent agreement of the Child Behavior Checklist (CBCL; Achenbach, 1991a) using data from a community sample of 317 high-risk families. The sample consisted of 218 families with alcoholism (biological mother, father, and son) and 99 matched comparison families without alcoholism; all families were intact and included a 3- to 5-year-old son at first contact. Evidence was found for the convergent validity of the CBCL. In addition, although interparent agreement was low, the internal structure was confirmed, and structural invariance was high between mothers and fathers and in families with and without alcoholism. The effects of parental psychological and cognitive functioning on parent agreement were examined and found to have a minimal effect on parent agreement. These results demonstrate the validity of the CBCL for use by parent raters with alcoholism and their sons and emphasize the importance of including both versus only 1 parent in research using the CBCL.

Relation between childhood disruptive behavior disorders and substance use and dependence symptoms in young adulthood: individuals with symptoms of attention-deficit/hyperactivity disorder and conduct disorder are uniquely at risk

Most prior literature examining the relations among attention-deficit/hyperactivity disorder (ADHD), conduct disorder (CD), and substance use and abuse suggests that CD fully account for the ADHD-substance abuse relation. This study sought to test an alternate theory that individuals with symptoms of both ADHD and CD are at a special risk for substance abuse. Relations between childhood ADHD and CD symptoms, and young adult tobacco, alcohol, marijuana, and hard drug use and dependence symptoms, were examined in a sample of 481 young adults. ADHD and CD symptoms interacted to predict marijuana dependence symptoms and hard drug use and dependence symptoms, such that individuals with high levels of both ADHD and CD had the highest levels of these outcomes.

CHIP: Defining a dimension of the vulnerability to attention deficit hyperactivity disorder (ADHD) using sibling and individual data of children in a community-based sample

We are taking a quantitative trait approach to the molecular genetic study of attention deficit hyperactivity disorder (ADHD) using a truncated case-control association design. An epidemiological sample of children aged 5 to 15 years was evaluated for symptoms of ADHD using a parent rating scale. Individuals scoring high or low on this scale were selected for further investigation with additional questionnaires and DNA analysis. Data in studies like this are typically complicated. In the study reported on here, individuals have from 1 to 4 questionnaires completed on them and the sample is composed of a mixture of singletons and siblings. In this paper, we describe how we used a genetic hierarchical model to fit our data, together with a twin dataset, in order to estimate genetic factor loadings. Correlation matrices were estimated for our data using a maximum likelihood approach to account for missing data. We describe how we used these results to create a composite score, the heritability of which was estimated to be acceptably high using the twin dataset. This score measures a quantitative dimension onto which molecular genetic data will be mapped.

Association of the dopamine beta hydroxylase gene with attention deficit hyperactivity disorder: genetic analysis of the Milwaukee longitudinal study

Attention deficit hyperactivity disorder (ADHD) is a highly heritable and common disorder that partly reflects disturbed dopaminergic function in the brain. Recent genetic studies have shown that candidate genes involved in dopamine signaling and metabolism contribute to ADHD susceptibility. We have initiated genetic studies in a unique cohort of 158 ADHD and 81 control adult subjects who have been followed longitudinally since childhood in the Milwaukee study of ADHD. From this cohort, genetic analysis was performed in 105 Caucasian subjects with ADHD and 68 age and ethnicity-matched controls for the DRD4 exon 3 VNTR, the SLC6A3 (DAT1) 3' UTR VNTR, dopamine beta hydroxylase (DBH) TaqI A polymorphism, and the DBH GT microsatellite repeat polymorphism that has been quantitatively associated with serum levels of DBH activity, but not previously studied in ADHD. Results indicate a significant association between the DBH TaqI A1 allele and ADHD (P = 0.018) with a relative risk of 1.33. The DBH GT repeat 4 allele, which is associated with high serum levels of DBH, occurred more frequently in the ADHD group than controls, but the difference did not reach statistical significance. Associations were not found with the SLC6A3 10 repeat or DRD4 7 repeat alleles. These results indicate that the DBH TaqI A allele, or another polymorphism in linkage disequilibrium with this allele, may confer increased susceptibility towards ADHD.

Psychopathology and social competencies of adolescents who were extremely low birth weight

BACKGROUND

We have previously shown that infants who were extremely low birth weight (ELBW) are particularly vulnerable to problems related to inattention and hyperactivity at school age. It is not known whether these problems persist to adolescence.

OBJECTIVE

To explore and compare the levels of psychopathology in a regional cohort of ELBW infants and sociodemographically matched term controls as reported by teens and their parents.

DESIGN/METHODS

Cross-sectional cohort study/geographically defined region.

PARTICIPANTS

TEENS: ELBW 141/169 (83%) and control 122/145 (84%), aged 12 to 16 years. PARENTS: ELBW 143/169 (85%) and control 123/145 (85%). Both cohorts and their parents completed the Ontario Child Health Study-Revised questionnaire with 6 behavioral subsca1es: conduct disorder, oppositional defiant disorder, attention-deficit/hyperactivity disorder (ADHD), overanxious, separation anxiety, and depression.

RESULTS

By teen self-report, there were no significant differences between ELBW and control teens on any of the 6 subscale scores. However, parents of ELBW teens reported significantly higher scores than parents of control for depression and ADHD based on 2-way analysis of variance (group x gender). Comparison within teen/parent dyads showed that both cohorts of teens reported significantly higher scores than their parents. Multivariable analyses on behavioral subscale scores demonstrated a number of variables that were significant predictors by parent report: group (ELBW vs control), gender, family function, developmental quotient, maternal mood, and socioeconomic status; no predictors were significant by teen report. There were no statistically significant interaction effects for any of the models. These models explained a greater percent of the variance in behavioral scores for parents than for teens (12.5%-22.0% vs 3.4%-8.2%). Results were similar when teens with neurosensory impairment were excluded.

CONCLUSIONS

This study is unique in the inclusion of both parent and teen self-report of behaviors. Significant differences were apparent only by parent report for ADHD and depression among ELBW teens. Significant predictors of behavioral scores for parents include group, gender, family function, developmental quotient, maternal mood, and socioeconomic status.

Parenting and the development of conduct disorder and hyperactive symptoms in childhood: a prospective longitudinal study from 2 months to 8 years

BACKGROUND

This study investigated the early processes involved in the development of symptoms of conduct disorder and hyperactivity.

METHOD

The study employed a prospective design, over a period from 2 months to 8 years. Detailed observational data of early and later mother-child interactions were collected, infant prefrontal function (the A not B task) was assessed, and symptoms of child conduct disorder and hyperactivity were rated by maternal report at age 5 and 8 years.

RESULTS

The principal findings of the study were that emotional dysregulation on the A not B task at 9 months predicted symptoms of conduct disorder at 5 and 8 years, and delayed object reaching times on the same task predicted hyperactive symptoms at 5 years. These two developmental trajectories were associated with distinct patterns of early parenting that were strongly influenced by infant gender. Thus, in boys early emotional dysregulation was predicted by rejecting and coercive parenting, and delayed reaching on the A not B task by coercive parenting, whereas in girls only continuity from earlier infant behaviour could be demonstrated. There was strong continuity between these early infant behaviours and later child disturbance that was partially mediated by parenting for conduct disorder symptoms (maternal hostile parenting in boys, and maternal coercive parenting in girls), but not for hyperactive symptoms.

CONCLUSIONS

These data would suggest that only in boys was there evidence for the existence of a sensitive period for the development of hyperactive symptoms, and to a lesser extent, conduct disorder symptoms.

ADHD treatment with once-daily OROS methylphenidate: interim 12-month results from a long-term open-label study

OBJECTIVE

Few treatment studies of attention-deficit/hyperactivity disorder (ADHD) extend beyond a few months. This article reports an interim analysis of a 24-month study evaluating the 12-month tolerability and effectiveness of a once-daily OROS formulation of methylphenidate (OROS MPH) in children with ADHD.

METHOD

Children, aged 6-13 years, with ADHD who participated in previous controlled studies and were MPH responders, received once-daily OROS MPH in this multicenter, open-label, nonrandomized study. Effectiveness was evaluated monthly by parents/caregivers and schoolteachers using validated rating scales (e.g., IOWA Conners). Safety and adverse events assessments involved objective (e.g., vital signs, growth) and subjective (sleep quality, tics) reporting.

RESULTS

Seventy-one percent of subjects (289/407) completed 12 months' treatment. Effectiveness was maintained throughout 12 months as demonstrated by stable IOWA Conners ratings and sustained improvements in peer interaction and Global Assessment Scale scores. OROS MPH was well tolerated, with adverse events similar to those expected with short-acting stimulant medication. OROS MPH had minimal impact on sleep quality and tics. There were no clinically meaningful changes in blood pressure, pulse, or height. The apparent absence of meaningful changes is tempered by the fact that children were MPH responders and were medicated at baseline, most for extended periods prior to enrollment.

CONCLUSION

In this open-label study, once-daily OROS MPH treatment appears to be well tolerated and effectiveness was maintained for up to 12 months in these children with ADHD.

Association of ADHD and conduct disorder--brain electrical evidence for the existence of a distinct subtype

BACKGROUND

To evaluate the impact of psychopathological comorbidity with oppositional defiant/conduct disorder (ODD/CD) on brain electrical correlates in children with attention deficit hyperactivity disorder (ADHD) and to study the pathophysiological background of comorbidity of ADHD+ODD/CD.

METHOD

Event-related potentials (ERPs) were recorded during a cued continuous performance test (CPT-A-X) in children (aged 8 to 14 years) with ICD-10 diagnoses of either hyperkinetic disorder (HD; n = 15), hyperkinetic conduct disorder (HCD; n = 16), or ODD/CD (n = 15) and normal children (n = 18). HD/HCD diagnoses in all children were fully concordant with the DSM-IV diagnosis of ADHD-combined type. ERP-microstates, i.e., time segments with stable brain electrical map topography were identified by adaptive segmentation. Their characteristic parameters and behavioral measures were further analyzed.

RESULTS

Children with HD but not comorbid children showed slower and more variable reaction times compared to control children. Children with HD and ODD/CD-only but not comorbid children displayed reduced P3a amplitudes to cues and certain distractors (distractor-X) linked to attentional orienting. Correspondingly, global field power of the cue-CNV microstate related to anticipation and preparation was reduced in HD but not in HCD. Topographical alterations of the HD occurred already in the cue-P2/N2 microstate. In sum, the comorbid group was less deviant than both the HD-group and the ODD/CD-group.

CONCLUSIONS

The findings suggest that HD children (ADHD-combined type without ODD/CD) suffer from a more general deficit (e.g., suboptimal energetical state regulation) including deficits of attentional orienting and response preparation than just a responseinhibitory deficit, backing the hypothesis of an involvement of a dysregulation of the central noradrenergic networks. The results contradict the hypothesis that ADHD+ODD/CD represents an additive co-occurrence of ADHD and ODD/CD and strongly suggest that it represents a separate pathological entity as considered in the ICD-10 classification system, which differs from both HD and ODD/CD-only.

The relation between attention deficit hyperactivity disorder and substance abuse: what role does conduct disorder play?

This paper presents a comprehensive review of the literature examining the relation between childhood attention deficit hyperactivity disorder (ADHD) and substance abuse. A number of researchers have statistically controlled for conduct disorder (CD) when examining the ADHD-substance-abuse relation. These studies have generally found that the ADHD-substance-abuse relation disappears when the high overlap between ADHD and CD is taken into account. On this basis, one may conclude that ADHD is unimportant to substance abuse. However, there is some evidence from both empirical studies and related fields that ADHD and CD may interact to afford a higher risk for substance abuse than may either disorder alone. Thus, ADHD appears to be important to substance abuse in that it interacts with CD to increase the risk. This paper calls for more research that directly examines the joint effects of ADHD and CD on risk for substance abuse. There is also a need for more research that examines gender differences, and mechanisms of the relations among ADHD, CD, and substance abuse.

Heritability of attention problems in children: I. cross-sectional results from a study of twins, age 3-12 years

Multiple twin studies of attention problems (AP) from the Child Behavior Checklist or ADHD from the DSM criteria have reported on the genetic and environmental influences on these behaviors. The majority of these have studied AP and ADHD symptoms in twin samples combined across wide age spans, combined rater information and both genders. Thus, it is possible that the results are complicated by developmental, informant, and gender differences. The purpose of this study was to assess for the genetic and environmental contributions to overactive behavior (a syndrome highly related to AP in 7-, 10-, and 12-years olds) in 3-years olds (3,671 twin pairs), and attention problems in 7- (3,373 twin pairs), 10- (2,485 twin pairs), and 12-years olds (1,305 twin pairs) while controlling for developmental, gender and rater contrast contributions. Using a cross-sectional twin design, contributions from genetic additive, genetic dominance, unique environmental and rater contrast effects were estimated for CBCL maternal reports. We found that genetic influences on overactive behavior and attention problems are high across an age span that covers pre-school and elementary school age. Although girls display less problem behavior compared to boys, heritability estimates were found equal for both genders at each age. Environmental experiences that are unique to the individual accounted for the remaining influence. At the age of 3 years, a rater contrast effect was detected. We hypothesize that the contrast effect represents a maternal rater bias effect that is dependent on the age of the twins. The implications of these findings are discussed with reference to the clinical setting and in the context of future research.

Childhood behavior disorders and injuries among children and youth: a population-based study

CONTEXT

While an association between pediatric behavioral disorders and injuries is generally acknowledged, no studies have measured the risk for injury in the context of a large, population-based study that is free of cohort biases.

OBJECTIVES

To examine the association between childhood behavior disorders ([CBDs] as indicated by prescription for methylphenidate [MPH]) and a variety of injury outcomes, and to evaluate the risk for injury among these children after controlling for known demographic correlates.

DESIGN

Population-based database analysis of all children in British Columbia (BC) under the age of 19 as of December 31, 1996; comparison of those who had been prescribed MPH and therefore placed in the CBD group (n = 16, 806) and those who were not (n = 1,010,067). Demographic information collected was as follows: age, sex, measures of socioeconomic status, and region of residence.

OUTCOME MEASURES

Common types of childhood injury in BC: International Classification of Diseases, Ninth Revision N-codes (fractures, open wounds, poisoning/toxic effect, concussion, intracranial, burns) and E-codes (falls, postoperative complications, motor vehicle accidents, struck by object, adverse effects of drugs, suffocation, drowning).

DATA SOURCE

BC Linked Health Data Set and the BC Triplicate Prescription Program.

RESULTS

After controlling for known demographic correlates, odds for injury was greater among those treated with MPH and presumed to have a behavioral disorder, when injury was characterized either by type (1.67; 99% confidence interval: 1.54-1.81) or cause (1.52; 99% confidence interval: 1.40-1.66) of injury. This increased risk extended to unexpected categories of injury such as postoperative complications and adverse effects of drugs.

CONCLUSIONS

Children with CBDs have >1.5 times the odds of sustaining injuries of a variety of types from a variety of causes, even after controlling for known demographic correlates, than those without behavioral disorders. The risks for these children extend beyond those that might be directly associated with impulsivity and overactivity. Injury prevention strategies aimed at this group of children and youth would be beneficial. Policy-makers should account for increased risk of a wide variety of injuries in this group of children and youth.

Does the treatment of attention-deficit/hyperactivity disorder with stimulants contribute to drug use/abuse? A 13-year prospective study

OBJECTIVE

To examine the impact of stimulant treatment during childhood and high school on risk for substance use, dependence, and abuse by young adulthood.

METHODS

A total of 147 clinic-referred hyperactive children were followed approximately 13 years into adulthood (mean: 21 years old; range: 19-25). At adolescent (age 15) and adult follow-up, probands were interviewed about their use of various substances and duration of stimulant treatment.

RESULTS

Duration of stimulant treatment was not significantly associated with frequency of any form of drug use by young adulthood. Stimulant-treated children had no greater risk of ever trying drugs by adolescence or any significantly greater frequency of drug use by young adulthood. Stimulant treatment in high school also did not influence drug use in adulthood except for greater use of cocaine. This difference was no longer significant after controlling for severity of attention-deficit/hyperactivity disorder and conduct disorder in childhood, adolescence, and adulthood. Stimulant treatment in either childhood or high school was not associated with any greater risk for any formal Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised drug dependence or abuse disorders by adulthood. Treatment with stimulants did not increase the risk of ever having tried most illegal substances by adulthood except for cocaine. Subsequent analyses showed that this elevated risk was primarily mediated by severity of conduct disorder by young adulthood and not by stimulant treatment in childhood.

CONCLUSION

This study concurs with 11 previous studies in finding no compelling evidence that stimulant treatment of children with attention-deficit/hyperactivity disorder leads to an increased risk for substance experimentation, use, dependence, or abuse by adulthood.

Economic implications of attention-deficit hyperactivity disorder for healthcare systems

Attention-deficit hyperactivity disorder (ADHD) is one of the most common chronic conditions of childhood, with adverse consequences that persist through adolescence into adulthood. Thus, the burden of illness associated with ADHD is high for affected individuals, their families, and society at large. This article reviews available information about ADHD-associated utilisation of healthcare resources, direct medical costs, and the costs or cost effectiveness of pharmacological interventions. Published estimates suggest that direct medical costs for youth with ADHD are approximately double those for youth without ADHD. Cross-sectional studies suggest that ADHD-associated incremental costs are highest for mental health services and pharmaceutical costs, and are greatest for youth with comorbid psychiatric conditions and for those being treated with stimulant medication. To guide relevant clinical and health policy, additional research is warranted on the following: source of increased costs observed among persons with ADHD; patient characteristics of those accruing high medical costs; and the long-term effect of ADHD treatment on direct and indirect costs.

Association analysis of monoamine oxidase A and attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is a highly heritable disorder. Although the causes of ADHD are unknown, dopaminergic, serotonergic and nor-adrenergic pathways have been strongly implicated. Monoamine Oxidase A (MAOA) is involved in the degradation of all three of these neurotransmitters and therefore has been suggested as a strong candidate gene for ADHD. Animal and human studies have implicated MAOA and 5-HT in impulsive and aggressive behavior. We therefore additionally postulated that MAOA might be associated with a subtype of ADHD where aggressive and impulsive features are especially prominent. We have tested this hypothesis by genotyping two polymorphisms (the 30-bp VNTR in the promoter and the Fnu4HI 941T-->G) in MAOA that are associated with altered MAOA function. Our sample consisted of 171 British Caucasian children 6-16 years of age fulfilling DSM-III R, DSM-IV or ICD-10 criteria for ADHD/Hyperkinetic Disorder. Using case control analysis and then the TDT, no association was found between these two MAOA polymorphisms and ADHD. Case control analysis of the VNTR showed an association with a subgroup of children with comorbid conduct problems (OR = 2.0, 95% CI = 1.09, 3.5), and TDT analysis indicated a statistical trend toward association. Our findings highlight the importance of phenotype definition and the need for the MAOA VNTR to be further examined.

Hyperactivity following postnatal NMDA antagonist treatment: reversal by D-amphetamine

Three experiments were performed to study the effects of neonatal administration of glutamate receptor antagonists, on either Day 11 (dizocilpine = MK-801, 3 x 0.5 mg/kg, s.c., injected at 0800, 1600 and 2400 h) or Day 10 (Ketamine, 1 x 50 mg/kg, s.c., or Ethanol-Low, 1 x 2.5 mg/kg, or, Ethanol-High, 2 x 2.5 mg/kg, s.c., with 2-h interval) to male mice pups, on spontaneous motor behavior, habituation to a novel situation and D-amphetamine-induced activity in the adult animals. Mice administered MK-801 showed initial hypoactivity followed by hyperactivity over the later (20-40 and 40-60 min) periods of testing. Mice administered Ketamine and Ethanol-High similarly displayed an initial hypoactivity followed by hyperactivity over the later time (20-60 min) of testing. Habituation to the novel activity test chambers was reduced drastically in the MK-801 mice compared with vehicle-treated mice. Similarly, mice administered Ketamine and Ethanol-High displayed too drastically reduced habituation behavior. The low dose of D-amphetamine (0.25 mg/kg) reduced the hyperactivity of neonatal MK-801-treated mice, particularly from 30-60 min onwards, and elevated the activity level of the vehicle-treated mice. Similarly, the low dose of D-amphetamine (0.25 mg/kg) reduced the hyperactivity of neonatally Ketamine-treated and Ethanol-High-treated mice, particularly from 30-60 min onwards, and elevated the activity level of the respective vehicle-treated mice. Fluoro-jade staining per mm(2) regional brain tissue of MK-801 mice pups expressed as percent of vehicle mice pups showed also that the extensiveness of staining was markedly greater in the parietal cortex, hippocampus, frontal cortex, and lesser so in the laterodorsal thalamus. Ketamine-treated mice showed cell degeneration mainly in the parietal cortex, whereas the Ethanol-High mice showed marked cell degeneration in both the parietal and laterodorsal cortex. The present findings that encompass a pattern of regional neuronal degeneration, disruptions of spontaneous motor activity, habituation deficits and reversal of hyperactivity by a low dose of D-amphetamine suggest a model of Attention Deficit Hyperactivity Disorder that underlines the intimate role of N-methyl-D-aspartate (NMDA) receptors in the developing brain.

Developmental course of ADHD symptomatology during the transition from childhood to adolescence: a review with recommendations

Although historically conceptualized as a disorder that was limited to males during middle childhood, ADHD is currently conceptualized as a chronic disorder that persists into adolescence and adulthood for both sexes. Nonetheless, the veracity of adult ADHD continues to be the source of debate. In order to frame this debate, research leading to the conceptualization of ADHD as a chronic disorder is reviewed. A distinction is made between the developmental outcomes versus the developmental course of ADHD. It is concluded that although childhood ADHD is associated with negative developmental outcomes in adolescence and adulthood, questions about the developmental course of ADHD remain. Although it appears that ADHD diminishes with advancing age, a number of methodological limitations prohibit firm conclusions. Recommendations for future studies are made with an emphasis on 1) overcoming extant methodological limitations in the literature and 2) the need for theoretically derived hypotheses regarding continuity and change in ADHD symptomatology over time.

Preschoolers at risk for attention-deficit hyperactivity disorder and oppositional defiant disorder: family, parenting, and behavioral correlates

This community study assigned 129 4-year-olds to groups at risk for attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), both ADHD and ODD, or no problems. Mothers of children at risk for ODD reported more family dysfunction, felt less competent as parents, suggested fewer solutions to child behavior problems, demonstrated a less assertive approach to child management, and reported more child internalizing problems than did mothers of children not elevated on ODD symptoms. Mothers of children at risk for ADHD reported higher personal depression scores than did those of the non-ADHD subgroup. Children at risk for ADHD evidenced the most difficulties in school where teachers reported more social behavior, classroom management, and internalizing problems relative to other children not at risk for ADHD. When solving child management problems, mothers of children in all groups suggested twice as many controlling/negative management strategies as positive/preventive strategies. In addition, faced with oppositional and conduct problems, mothers of children in all groups increased controlling/negative suggestions and decreased positive/preventive suggestions. Mothers of girls at risk for ADHD, ODD, and ADHD/ODD gave more rewards per positive behavior than did mothers of boys.

Effect of potent CYP2D6 inhibition by paroxetine on atomoxetine pharmacokinetics

The purpose of this study was to characterize the effect of potent CYP2D6 inhibition byparoxetine on atomoxetine disposition in extensive metabolizers. This was a single-blind, two-period, sequential studyin 22 healthy individuals. In period 1, 20 mg atomoxetine bid was administered to steady state. In period 2, 20 mg paroxetine was administered qd for 17 days. On days 12 through 17, 20 mg atomoxetine bid were coadministered. Plasma pharmacokinetics of atomoxetine, 4-hydroxyatomoxetine, and N-desmethylatomoxetine was determined at steady state in each treatment period. Plasma pharmacokinetics of paroxetine were determined after the 11th and 17th doses. Paroxetine increased C(ss,max), AUC0-12, and t1/2 of atomoxetine by approximately 3.5-, 6.5-, and 2.5-fold, respectively. After coadministration with paroxetine, increases in N-desmethylatomoxetine and decreases in 4-hydroxyatomoxetine concentrations were observed. No changes in paroxetine pharmacokinetics were observed after coadministration with atomoxetine. It was concluded that inhibition of CYP2D6 by paroxetine markedly affected atomoxetine disposition, resulting in pharmacokinetics similar to poor metabolizers of CYP2D6 substrates.

Neuropsychological performance in DSM-IV ADHD subtypes: an exploratory study with untreated adolescents

OBJECTIVE

To explore neuropsychological performance in untreated Brazilian adolescents suffering from attention-deficit hyperactivity disorder (ADHD).

METHOD

We assessed 30 untreated adolescents with ADHD and 60 healthy control subjects, aged 12 to 16 years, using a neuropsychological battery including the Wisconsin Card-Sorting Test (WCST), the Stroop Test (ST), the Digit Span, and the Word Span.

RESULTS

We found neuropsychological differences among the DSM-IV ADHD subtypes. Adolescents with the predominantly inattentive subtype (ADHD-I) performed more poorly than did control subjects on both the Digit Span and the ST. On both the Digit Span and the WCST, adolescents with the combined subtype (ADHD-C) presented significantly more impairments than did control subjects. Adolescents with the predominantly hyperactive-impulsive type (ADHD-HI) did not differ significantly from the control subjects in any measure assessed, but had a better performance than did those with ADHD-C on both the Digit Span and the WCST. In addition, adolescents with ADHD-HI performed better on the ST than did adolescents with ADHD-I.

CONCLUSIONS

These findings suggest cognitive differences among ADHD subtypes, supporting the diagnostic distinction among them. Adolescents with ADHD-HI do not seem to have significant cognitive deficits.

Cigarette smoking and psychiatric comorbidity in children and adolescents

OBJECTIVE

To review the current state of knowledge of psychiatric comorbidity in adolescent cigarette smokers.

METHOD

assisted literature search was conducted and seminal articles were cross-referenced for comprehensiveness of the search. For each disorder, a synopsis of knowledge in adults is provided and compared with the knowledge in adolescents.

RESULTS

Psychiatric comorbidity is common in adolescent cigarette smokers, especially disruptive behavior disorders (such as oppositional defiant disorder, conduct disorder, and attention-deficit/hyperactivity disorder), major depressive disorders, and drug and alcohol use disorders. Anxiety disorders are modestly associated with cigarette smoking. Both early onset (<13 years) cigarette smoking and conduct problems seem to be robust markers of increased psychopathology, including substance abuse, later in life. In spite of the high comorbidity, very few adolescents have nicotine dependence diagnosed or receive smoking cessation treatment in child and adolescent psychiatric treatment settings.

CONCLUSIONS

There is increasing evidence for high rates of psychiatric comorbidity in adolescent cigarette smokers. Cigarette smoking in adolescence appears to be a strong marker of future psychopathology. Child and adolescent psychiatry treatment programs may be a good setting for prevention efforts and treatment, which should focus on both nicotine dependence and psychiatric disorders.

Young adult follow-up of hyperactive children: self-reported psychiatric disorders, comorbidity, and the role of childhood conduct problems and teen CD

We report on the psychiatric disorders present at young adult follow-up (Mean age 20-21 years; 13+ year follow-up) and the comorbidity among them for a large sample of hyperactive (H; N = 147) and community control (CC; N = 71) children. The H group had a significantly higher risk for any nondrug psychiatric disorders than the CC group (59% vs. 36%). More of the H group met criteria for ADHD (5%); major depressive disorder (26%); and histrionic (12%), antisocial (21%), passive-aggressive (18%), and borderline personality disorders (14%) at follow-up than the CC group. Severity of childhood conduct problems contributed to the risk for passive-aggressive, borderline, and antisocial personality disorders. But it only affected risk for antisocial personality after controlling for severity of teen conduct disorder (CD), which also contributed to the risk for these same 3 disorders. Examination for comorbidity among these disorders indicated that presence of either borderline or antisocial personality disorder significantly increased the risk for major depression and the other significant personality disorders. More of the hyperactive group had received various forms of mental health treatment during and since leaving high school than the control group. Results suggest that hyperactive children are at significant risk for at least 1 nondrug disorder in young adulthood, principally major depression and several personality disorders, and that this risk is largely mediated by severity of CD at adolescence.

Effect of resident and direct-care staff training on responding during social interactions

The effectiveness of a multifaceted training package was evaluated for inappropriate social behavior of five children with mild mental retardation and attention deficit hyperactivity disorder (ADHD), who resided in a facility. The procedure encompassed resident training with video feedback and self-management and direct-care staff training with video and graphic feedback. Resident training occurred on an individual basis; feedback to staff was presented during routine staff meetings. Results showed increases of appropriate staff responses to residents' behavior. However, the effect of the package on residents' inappropriate social responses proved to be ineffective. Differences with previous studies as well as the need for research into procedural variables that affect social behavior of children with ADHD and mild mental retardation are discussed.

How do mothers' childrearing histories, stress and parenting affect children's behavioural outcomes?

BACKGROUND

Information is needed to understand the role of low to moderate levels of mothers' emotional stress and child characteristics (i.e. prematurity) on parenting behaviours and their impact on children's behaviour that might be deemed 'challenging' but not 'disordered'.

METHODS

The direct and indirect relations of maternal childrearing history and emotional stress, and observed parenting practices when children were 3 years of age on 4-year child behavioural outcomes was examined in a sample of low-income families with a term (n=112) or preterm (n=180) child. Parenting practices included displays of warmth and restrictiveness when interacting with their children. Child outcomes at 4 years included observation of social initiations with their mothers and maternal report of social and attentional problems.

RESULTS

A Structural Equation Model building approach guided by specific hypotheses indicated that preterm as compared to full-term children had more maternal reported social and attentional problems but did not differ in observed social initiating skills. Greater negative maternal childrearing history indirectly influenced social initiating skills through its direct influence on maternal emotional stress. Greater maternal emotional stress directly influenced mothers' parenting that, in turn, directly influenced social initiating. Prematurity and a more negative childrearing history had a direct negative influence on the maternal report of social and attentional behavioural outcomes.

CONCLUSIONS

These findings delineate the effects of prematurity and maternal parenting on the behaviour of 4-year-old-children and extend current knowledge of the influence of parental emotional stress on parenting. Even milder levels can negatively influence parenting, and in turn, contribute to children's less well developed social skills. The issues raised in this study could help with the identification and prioritization of medical and psychological services.

An experimental comparison of Pycnogenol and methylphenidate in adults with Attention-Deficit/Hyperactivity Disorder (ADHD)

Twenty-four adults (24 to 53 years old) with Attention-Deficit/Hyperactivity Disorder (ADHD), Combined Type, were studied in a double-blind, placebo-controlled, crossover study of Pycnogenol and methylphenidate. Pycnogenol is an antioxidant derived from the bark of the French maritime pine tree. Methylphenidate is a standard pharmaceutical intervention for ADHD. Anecdotal reports suggest that Pycnogenol improves concentration in adults with ADHD without adverse side effects. Participants received Pycnogenol, methylphenidate, and placebo, each for three weeks, in a randomized and counterbalanced order. Although ADHD symptoms improved during treatment, neither methylphenidate nor Pycnogenol outperformed the placebo control, as measured by self-report rating scales, rating scales completed by the individual's significant other, and a computerized continuous performance test. The conservative dosage levels and relatively brief length of treatment may have contributed to the absence of significant differences among treatment conditions. Implications for future research are noted.

A randomized, double-blind, placebo-controlled, parallel-group study of SLI381 (Adderall XR) in children with attention-deficit/hyperactivity disorder

OBJECTIVE

SLI381 (Adderall XR) is a 2-component extended-release capsule formulation of Adderall designed to produce a therapeutic effect that lasts throughout the day with 1 morning dose. The primary objective of this study was to assess the efficacy and safety of SLI381 compared with placebo in the treatment of attention-deficit/hyperactivity disorder (ADHD) in children in a naturalistic school and home setting. A secondary objective was to assess the diurnal variation in responses based on morning and afternoon assessments.

METHODS

A multicenter, randomized, double-blind, parallel-group, placebo-controlled trial was conducted at 47 sites. After a 1-week washout of any previous stimulant medication, patients were randomized to receive single-daily morning doses of placebo or SLI381 10 mg, 20 mg, or 30 mg for 3 weeks. Participants aged 6 to 12 years inclusive who satisfied Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria diagnosis of ADHD were included. The primary efficacy parameter was the Conners Global Index Scale for Teachers. Secondary efficacy parameters included the Conners Global Index Scale for Parents, the Clinical Global Impressions Scale for improvement, and the Parent Global Assessment for improvement. Safety was assessed by recording adverse events, laboratory tests, and vital signs at each visit during the study. Physical examinations and electrocardiograms were performed at the screening and the end of the study.

RESULTS

Five hundred eighty-four children were randomized, 563 were included in the intent-to-treat population, and 509 completed the entire study. Intention-to-treat analysis of Conners Global Index Scale for Teachers and Conners Global Index Scale for Parents scores revealed significant improvement in morning, afternoon, and late afternoon behavior for all active treatment groups versus placebo. All active treatment groups showed significant dose-related improvement in behavior from baseline. Both the Clinical Global Impressions Scale for improvement and Parent Global Assessment for improvement showed all doses of SLI381 to be superior to placebo at treatment end and both confirmed the dose-response relationship between improvement and the SLI381 dose. The incidence of spontaneously reported adverse events was low and similar for active treatments and placebo.

CONCLUSIONS

SLI381 produced consistent, dose-related improvements on all measures of efficacy. The extended-release nature of the SLI381 formulation was shown by continued, significant improvement in afternoon assessments by teachers and afternoon and late afternoon assessments by parents. The time course and therapeutic effects of SLI381 suggests that this medication is an efficacious once-daily treatment for children with ADHD.