Anxiety as a predictor and outcome variable in the multimodal treatment study of children with ADHD (MTA)

Meta-Analysis: Reduced Risk of Anxiety with Psychostimulant Treatment in Children with Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Anxiety is a commonly reported side-effect of psychostimulant treatment. Our goal was to quantify the risk of anxiety as a side effect of psychostimulant treatment for attention-deficit/hyperactivity disorder (ADHD).

METHODS

We conducted a PubMed search to identify all double-blind, randomized, placebo-controlled trials examining the efficacy of psychostimulant medications in the treatment of children with ADHD. We used a fixed-effects meta-analysis to examine the risk ratio of anxiety reported as a side effect in children treated with psychostimulants compared with those treated with placebo. We used stratified subgroup analysis and meta-regression to examine the effects of stimulant type, dosage, duration of use, and trial design on the measured risk of anxiety.

RESULTS

We identified 23 studies involving 2959 children with ADHD for inclusion in our meta-analysis. The risk of anxiety associated with psychostimulant treatment was significantly lower than that experienced with placebo (relative risk [RR] = 0.86 [95% CI: 0.77, 0.95], z = -2.90, p < 0.05). Higher doses of psychostimulants were associated with a reduced measured risk of anxiety of psychostimulants when compared with placebo (β = -0.0039 [95% CI: -0.00718, -0.00064], z = -2.34, p = 0.019).

CONCLUSIONS

Meta-analysis suggests that treatment with psychostimulants significantly reduced the risk of anxiety when compared with placebo. This finding does not rule out the possibility that some children experience increased anxiety when treated with psychostimulants, but suggests that those risks are outweighed by the number of children who experience improvement in anxiety symptoms (possibly as a secondary effect of improved control of ADHD symptoms). Clinicians should consider rechallenging children with ADHD who report new-onset or worsening anxiety with psychostimulants, as these symptoms are much more likely to be coincidental rather than caused by psychostimulants.

Evaluation of the Duration of Action and Comparative Effectiveness of Lisdexamfetamine Dimesylate and Behavioral Treatment in Youth With ADHD in a Quasi-Naturalistic Setting

OBJECTIVE

This study compared the relative effects of three treatment conditions: long-acting stimulant medication (MED), behavior modification, and medication/behavioral treatments combined (COM) in children with ADHD.

METHOD

A total of 25 children, aged 6 to 12 years, received the three treatment conditions during a 7-week Summer Treatment Program in an alternating treatments design. Counselors completed behavioral ratings from 0.5 to 12.5 hr post dose, and parents completed nighttime ratings.

RESULTS

Ratings for SKAMP (Swanson, Kotkin, Agler, M-Flynn, and Pelham) and for following instructions indicated COM and MED improved symptoms over BEH treatment beginning 3 hr post dose (p = .008), with ratings maintained 12.5 hr post dose (p = .001 and .006). Results for frustration tolerance indicated significant improvement in all three conditions until 9 hr post dose.

CONCLUSION

MED and COM separated from BEH at 3 hr post dose, and sustained benefit was observed across the day for two of three measures. BEH appears to have an additive effect, extending the duration of frustration tolerance.

Anxiety in college students With ADHD: relationship to cognitive functioning

OBJECTIVE

This study sought to explore how anxiety impacts college students with ADHD, especially with regard to cognitive functioning.

METHOD

473 college students with ADHD and a control group of 200 college students without ADHD completed self-report measures of anxiety, ADHD symptomatology and tests of cognitive functioning.

RESULTS

Students with ADHD reported significantly more anxiety than students without ADHD. Within the ADHD group, the relationship between anxiety and inattention was similar to the relationship between anxiety and hyperactivity/impulsivity. Students with ADHD reported more anxiety with regard to academics compared to life-in-general. There were no gender differences for anxiety; however, freshman indicated more anxiety than upper-classmen. Anxiety and inattention were found to interact such that students with low levels of inattention but high levels of anxiety performed better on tasks of cognitive ability.

CONCLUSION

Anxiety in college students with ADHD can take many forms, and interventions require a multi-focused approach. There may be some positive aspects to anxiety.

ADHD, Multimodal Treatment, and Longitudinal Outcome: Evidence, Paradox, and Challenge

Given major increases in the diagnosis of attention-deficit hyperactivity disorder (ADHD) and in rates of medication for this condition, we carefully examine evidence for effects of single versus multimodal (i.e., combined medication and psychosocial/behavioral) interventions for ADHD. Our primary data source is the Multimodal Treatment Study of Children with ADHD (MTA), a 14-month, randomized clinical trial in which intensive behavioral, medication, and multimodal treatment arms were contrasted with one another and with community intervention (treatment-as-usual), regarding outcome domains of ADHD symptoms, comorbidities, and core functional impairments. Although initial reports emphasized the superiority of well-monitored medication for symptomatic improvement, reanalyses and reappraisals have highlighted (a) the superiority of combination treatment for composite outcomes and for domains of functional impairment (e.g., academic achievement, social skills, parenting practices); (b) the importance of considering moderator and mediator processes underlying differential patterns of outcome, including comorbid subgroups and improvements in family discipline style during the intervention period; (c) the emergence of side effects (e.g., mild growth suppression) in youth treated with long-term medication; and (d) the diminution of medication's initial superiority once the randomly assigned treatment phase turned into naturalistic follow-up. The key paradox is that whereas ADHD clearly responds to medication and behavioral treatment in the short term, evidence for long-term effectiveness remains elusive. We close with discussion of future directions and a call for greater understanding of relevant developmental processes in the attempt to promote optimal, generalized, and lasting treatments for this important and impairing neurodevelopmental disorder.

Anxiety in young people with ADHD: clinical and self-report outcomes

OBJECTIVE

(a) To determine the prevalence of comorbid anxiety disorder in ADHD, defined by diagnostic criteria and (b) to compare anxiety as reported by parents and participants with clinician assessment.

METHOD

Children with ADHD were assessed for comorbid anxiety disorder using the Anxiety Disorder Interview Schedule for Children. Parent report (Conners' Parent Rating Scale-Revised: Long version) and self-report (State-Trait Anxiety Inventory and Brain Resource Inventory for Screening Cases-Child version) scales were used to assess anxiety. The ADHD-Rating Scale IV was used to measure ADHD symptoms.

RESULTS

Of 134 participants (11.0 ± 2.6 years), 31.3% had comorbid anxiety disorder. Comorbid anxiety disorder was associated with greater severity of ADHD. Anxiety symptoms from parent reports (p < .05) but not from child/self-report (p > .05) correlated with clinician assessment.

CONCLUSION

Assessment for comorbid anxiety disorder and inclusion of parent rating in this assessment are important components of ADHD treatment in children and adolescents.

Differentiating Anxiety and Depression in Relation to the Social Functioning of Young Adolescents With ADHD

The present study examined anxiety and depressive symptoms in relation to the social functioning of young adolescents with attention-deficit/hyperactivity disorder (ADHD) and builds upon prior work by incorporating youths' self-reports of internalizing symptoms and examining distinct anxiety and depression dimensions to increase specificity. Participants were 310 young adolescents (ages 10-14; 71% male, 78% Caucasian) diagnosed with ADHD. Youth provided ratings of anxiety/depression, and parents provided ratings of their own depression. Parents and youth both reported on youths' social skills and perceived social acceptance. Path analyses indicated that above and beyond child demographics, ADHD and oppositional defiant disorder symptom severity, and parents' own depression, self-reported social anxiety and anhedonia were both associated with lower youth-reported social skills and both parent- and youth-reported social acceptance. Negative self-evaluation was associated with poorer parent-reported social skills. Finally, harm avoidance was positively associated with both youth- and parent-reported social skills. A path analysis using comorbid diagnoses (rather than symptom dimensions) indicated that that having a comorbid disruptive behavior disorder or depression diagnosis (but not a comorbid anxiety diagnosis) was associated with poorer parent-reported social functioning. Results demonstrate that the relation between internalizing symptoms and social functioning among young adolescents with ADHD is nuanced, with social anxiety and anhedonia symptoms associated with lower social skills and social acceptance in contrast to harm avoidance being associated with higher ratings of social skills (and unrelated to social acceptance). In terms of comorbid diagnoses, depression is more clearly related than anxiety to poorer social functioning among young adolescents with ADHD. These results point to the importance of attending to specific facets of anxiety and depression in clinical care and future research.

Association between ADHD symptoms and anxiety symptoms in Taiwanese adolescents

OBJECTIVE

The aims of this cross-sectional study were to examine the association between significant ADHD symptoms and the four domains of anxiety symptoms on the Taiwanese version of Multidimensional Anxiety Scale for Children (MASC-T) and to examine the moderating effects of sociodemographic characteristics on this association among Taiwanese adolescents in the community.

METHOD

A total of 4,716 adolescents in Grades 7 through 12 in southern Taiwan completed the MASC-T, the ADHD Self-Rated Scale, the Mandarin Chinese version of the Center for Epidemiological Studies Depression Scale, the Rosenberg Self-Esteem Scale, and a questionnaire about sociodemographic characteristics. Multiple regression analysis was used to examine both the association of significant ADHD symptoms with four domains of anxiety symptoms on the MASC-T and the moderating effects of sociodemographic characteristics on this association.

RESULTS

The adolescents with significant ADHD symptoms had more severe total anxiety symptoms, physical symptoms, social anxiety symptoms, and separation/panic symptoms for three domains of the MASC-T but less harm avoidance than did those without significant ADHD symptoms. Age, gender, and low self-esteem had moderating effects on the association between significant ADHD symptoms and anxiety symptoms for some domains of the MASC-T.

CONCLUSION

The results of this study suggest a significant association between significant ADHD symptoms and the severity of anxiety symptoms in adolescents. Clinicians must evaluate anxiety symptoms among adolescents with ADHD and arrange comprehensive treatment programs.

When attention-deficit/hyperactivity disorder co-occurs with anxiety disorders: effects on treatment

Anxiety disorders (ANX) and attention-deficit/hyperactivity disorder (ADHD) commonly co-occur; this comorbidity is associated with a high degree of impairment and a poor long-term prognosis. In this review, the nature of this comorbidity and its treatment will be described, and an approach to treating children with ANX + ADHD will be presented. The etiology of ANX + ADHD is controversial, with biological, developmental, environmental and cognitive factors examined in various studies. There is increasing evidence that ANX + ADHD may be distinct from each separate disorder, and may represent a neuropsychiatric condition that involves dysregulation in both anxiety and ADHD domains. Treatment usually requires a combination of medication and psychotherapeutic intervention. Stimulant medications have been found most helpful so far compared with other medications, although atomoxetine is also being studied. There is limited evidence for selective serotonin reuptake inhibitors, and their potential for behavioral activation may be problematic in these children. Intensive behavior modification was shown to be beneficial in conjunction with medication for ANX + ADHD in a multimodal treatment study of children with ADHD. Cognitive-behavioral therapy has been used to address anxiety symptoms, but may need to be individualized in ANX + ADHD as cognitive limitations and ADHD behaviors may otherwise interfere. Parental anxious or ADHD traits and the child's developmental level must also be considered to optimize treatment.

Examination of spatial working memory performance in children and adolescents with attention deficit hyperactivity disorder, combined type (ADHD-CT) and anxiety

Spatial working memory (SWM) is known to be impaired in children with ADHD-CT, whether anxiety is present or not. Yet, it remains unclear whether anxiety disorders add to the SWM impairments evident in ADHD-CT and whether these findings extend into adolescents with ADHD-CT and anxiety. Further, it is not yet known whether children and adolescents with carefully defined anxiety disorders alone, demonstrate SWM deficits. This study explored the association of SWM and its strategy and spatial span components in carefully defined children and adolescents (age 6-16 years) with ADHD-CT alone (N = 163; 14 % female), ADHD-CT and anxiety (N = 243; 23 % female), anxiety disorders alone (N = 69; 25 % female) compared to age- and gender-matched healthy control participants (N = 116; 19 % female). The relationship between SWM and its strategy and span components and core ADHD-CT symptoms and anxiety symptoms were also examined. There was no evidence of an additive effect of ADHD and anxiety on SWM, strategy and spatial span deficits. But, anxiety disorders alone were associated with impaired SWM and span performance compared to healthy control participants. In contrast, strategy did not differ between children and adolescents with anxiety disorders alone and healthy control participants, suggesting that with anxiety span is the most affected component. Further, these findings were age-independent. This study concurs with and extends current influential models about the cognitive effects of anxiety on performance in the setting of ADHD-CT. Clinical implications and future research directions are discussed.

Relationship between anxiety, anxiety sensitivity and conduct disorder symptoms in children and adolescents with attention-deficit/hyperactivity disorder (ADHD)

Attention-deficit hyperactivity disorder (ADHD) is often comorbid with anxiety disorders and previous studies observed that anxiety could have an impact on the clinical course of ADHD and comorbid disruptive behavioral disorders (conduct disorders and oppositional-defiant disorders). Anxiety sensitivity (AS) is a different concept from anxiety per se and it is believed to represent the constitutionally based sensitivity of individuals to anxiety and anxiety symptoms. We aimed to assess the associations between anxiety, AS and symptoms of disruptive behavioral disorders (DBD) in a clinical sample of children and adolescents with ADHD. The sample consisted of 274 treatment naive children with ADHD aged 8-17 years. The severity of ADHD symptoms and comorbid DBD were assessed via parent rated Turgay DSM-IV-Based Child and Adolescent Behavioral Disorders Screening and Rating Scale (T-DSM-IV-S), Conners' Parent Rating Scale (CPRS), and Conners' Teacher Rating Scale (CTRS). AS and severity of anxiety symptoms of children were evaluated by self-report inventories. The association between anxiety, AS, and DBD was evaluated using structural equation modeling. Analyses revealed that AS social subscale scores negatively predicted symptoms of conduct disorder (CD) reported in T-DSM-IV-S. On the other hand, CD symptoms positively predicted severity of anxiety. No direct relationships were detected between anxiety, AS and oppositional-defiant behavior scores in any scales. These results may suggest a protective effect of AS social area on the development of conduct disorder in the presence of a diagnosis of ADHD, while the presence of symptoms of CD may be a vulnerability factor for the development of anxiety symptoms in children and adolescents with ADHD.

Attention and internalizing behaviors in relation to white matter in children born preterm

OBJECTIVE

Diffusion tensor imaging (DTI) is a magnetic resonance imaging technique that provides quantitative characterization of white matter tracts in the brain. This study used DTI to examine the degree of association between parent-rated scores of attention, internalizing behaviors including anxiety symptoms, and externalizing behaviors and white matter fractional anisotropy (FA) in children born preterm.

METHODS

Participants were aged 9 to 16 years; 25 were born at <36 weeks of gestation (mean = 28.6 wk, birth weight = 1191 g) and 20 were full term. The authors analyzed the results using Tract-Based Spatial Statistics, a technique that generates a skeleton representing the core of white matter tracts throughout the brain. The authors examined the correlations between behavior scores and FA of (1) the whole skeleton and (2) the specific regions of interest.

RESULTS

In preterm children, scores on attention and internalizing behavior scales were each associated with whole skeleton FA and several regions of interest; unfavorable scores were consistently associated with lower FA. Externalizing behaviors were not associated with whole skeleton FA, but significant associations were found within a few regions of interest. The network of significant regions for attention and internalizing symptoms was widely distributed and overlapping. In full-term children, no associations of FA and behavior were significant.

CONCLUSIONS

Attention and internalizing behaviors in preterm children were associated with FA in a widely distributed overlapping network of white matter tracts, suggesting common underlying neurobiology. DTI contributes to understanding individual differences in attention and behavior characteristics in children born preterm.

Comorbid anxiety and neurocognitive dysfunctions in children with ADHD

Previous research established that children with ADHD and comorbid anxiety have a later age of ADHD onset, show less off-task and hyperactive behavior, and have more school problems than children with ADHD alone. Comorbid anxiety appears to ameliorate behavioral inhibition deficits, worsen working memory problems, and lengthen reaction times in ADHD. This study investigated the effect of comorbid anxiety on a broad range of neurocognitive functions and includes child-, parent- and teacher reports of anxiety. The sample consisted of 509 children in the age range 5-19 years, including 238 children with a diagnosis of ADHD combined subtype and 271 normal control children. Children were tested on a broad battery of neurocognitive tasks that proved highly sensitive to ADHD in previous work. Linear Structural Equation Modeling (SEM) was used to estimate the effect of comorbid anxiety on the neurocognitive functions. Child reported anxiety was associated with slower motor speed and response speed and better behavioral inhibition. Teacher reported anxiety was related to worse time production. Parent reported anxiety was not significantly associated with any of the neurocognitive functions. Compared to parent and teacher reports of anxiety, child reported comorbid anxiety shows foremost the largest associations with the neurocognitive dysfunctions observed in children with ADHD. This stresses the importance of including child self-reported anxiety assessments in clinical and research practice.

Adolescent ADHD and adult physical and mental health, work performance, and financial stress

OBJECTIVE

There is a scarcity of longitudinal studies of adolescents with attention-deficit/hyperactivity disorder (ADHD) followed until adulthood. We studied the relationship between ADHD in adolescence and impaired general physical health, impaired general mental health, antisocial personality disorder, impaired work performance, and high financial stress in adulthood.

METHODS

A prospective design incorporated 6 assessments of participants spanning mean ages from 14 to 37 years. Two baseline assessments were taken between ages 14 and 16 years, and 5 outcome assessments were taken at mean age 37 years. Participants were assessed with structured interviews and questionnaires. The participants were from a community sample of individuals initially drawn in 1975 and followed to a mean age of 37 years in 2009.

RESULTS

The adjusted odds ratios and 95% confidence intervals (CIs) for ADHD in adolescence as related to internal stress in adulthood were 1.82 (95% CI = 1.01-3.25; P < .05) for impaired general physical health, 2.36 (95% CI = 1.23-4.51; P < .01) for impaired general mental health, and 3.28 (95% CI = 1.51-7.13; P < .01) for antisocial personality disorder. The adjusted odds ratios and 95% CIs for ADHD in adolescence as related to external stress were 2.46 (95% CI = 1.37-4.43; P < .01) for impaired work performance and 3.33 (95% CI = 1.70-6.55; P < .001) for high financial stress.

CONCLUSIONS

Clinicians should focus on early diagnosis and treatment of adolescent ADHD because it is a major predictor of an array of physical, mental, work, and financial problems in adulthood.

ADHD and autism: differential diagnosis or overlapping traits? A selective review

According to DSM-IV TR and ICD-10, a diagnosis of autism or Asperger Syndrome precludes a diagnosis of attention-deficit/hyperactivity disorder (ADHD). However, despite the different conceptualization, population-based twin studies reported symptom overlap, and a recent epidemiologically based study reported a high rate of ADHD in autism and autism spectrum disorders (ASD). In the planned revision of the DSM-IV TR, dsm5 (www.dsm5.org), the diagnoses of autistic disorder and ADHD will not be mutually exclusive any longer. This provides the basis of more differentiated studies on overlap and distinction between both disorders. This review presents data on comorbidity rates and symptom overlap and discusses common and disorder-specific risk factors, including recent proteomic studies. Neuropsychological findings in the areas of attention, reward processing, and social cognition are then compared between both disorders, as these cognitive abilities show overlapping as well as specific impairment for one of both disorders. In addition, selective brain imaging findings are reported. Therapeutic options are summarized, and new approaches are discussed. The review concludes with a prospectus on open questions for research and clinical practice.

Association of anxiety and ODD/CD in children with and without ADHD

The goal of this study is to examine levels of oppositional defiant disorder (ODD) and conduct disorder (CD) in four groups of children: attention-deficit/hyperactivity disorder (ADHD) only, anxiety only, ADHD and anxiety, and controls (i.e., non-ADHD youth). Although children with ADHD exhibit more ODD and CD than non-ADHD youth, it is unknown if anxiety is associated with increased or decreased ODD and CD in children with ADHD. We examined parent and teacher ratings of ODD and CD from the Disruptive Behavior Disorder Rating Scale in 203 school age children (ages 6-9); 70% were male, and 47% were Caucasian. Children were divided into four diagnostic groups based on ADHD and anxiety status from the Diagnostic Interview Scale for Children. According to parents, children with ADHD and anxiety had the highest levels of ODD/CD, followed by children with ADHD only (i.e., without anxiety). Children with anxiety only and controls had lowest ODD and CD scores, and these groups did not differ from each other. The same patterns were found according to teacher report, except that the anxiety only group had significantly lower levels of ODD than non-ADHD controls. Further, combined type ADHD youth with anxiety exhibited the highest levels of ODD and CD compared to all other groups. Comorbid anxiety may strengthen the association of ADHD and ODD/CD, particularly in the combined subtype. We discuss the importance of comorbid anxiety to the development of externalizing problems as well as potential explanatory factors underlying elevated ODD and CD among children with ADHD and anxiety.

Comorbidity of conduct disorder symptoms and internalising problems in children: investigating a community and a clinical sample

Previous studies have demonstrated that many children with conduct problems (CP) also show internalising psychopathology (IP). However, it remains unclear whether the presence of IP serves as a protective or risk factor for the severity and development of CP. The aim of the present study was to assess the prevalence and associations of comorbid IP in children with CP in a community and a clinical sample. Data from boys as well as girls with CP in the clinical range were obtained from a community sample (n = 1,160) and a clinical sample diagnosed with disruptive behaviour disorder (n = 193) from two European countries. In the community sample, information was obtained using the strengths and difficulties questionnaire, whereas in the clinical sample, the child behaviour checklist was used. Internalising disorders, according to ICD-10, were also assessed in the clinical sample. For both samples, age, gender, and impact of comorbid IP in the clinical range (above 90th percentile) for CP were explored. Results revealed that in both samples, participants with CP showed a high rate of comorbid IP (community sample: 35%; clinical sample: 78%). Participants with comorbid IP were more likely to experience social problems with peers. In the clinical sample, comorbid IP rated by the parents was more prevalent than internalising disorders according to ICD-10. Boys with CP and comorbid IP demonstrated a higher severity of externalising behaviour than boys without comorbid IP in the clinical sample. We concluded that in both samples, we found a high co-occurrence of CP and IP. Based on the idea that the co-occurrence of IP and CP in children and adolescents may potentially lead to increased antisocial behaviour, internalising psychopathology should be carefully investigated. Effective strategies and specific risk factors must be evaluated to treat comorbidity as early as possible in children with CP and IP.

Influence of anxiety on the social functioning of children with and without ADHD

OBJECTIVE

This investigation examined the contribution of anxiety to the social functioning of children with and without ADHD.

METHOD

Participants were 62 children with ADHD (ages 6-10 years and 68% boys) and 62 age- and sex-matched comparison children. Children's social functioning was measured through parent and teacher reports, observations of social behaviors during a lab-based playgroup with previously unacquainted peers, and peer nominations during that lab-based playgroup.

RESULTS

Anxiety symptoms incrementally predicted adult-informant reports of poorer social functioning after controlling for demographic covariates, ADHD status, and oppositional-defiant disorder (ODD) status. However, anxiety was not associated with peer nominations received at the playgroup. There were some indications that anxiety may have greater influence on the functioning of comparison children relative to children with ADHD or ODD.

CONCLUSION

Anxiety may contribute to the peer problems of children both with and without ADHD.

Looking to the future of research in pediatric anxiety disorders

OBJECTIVE

The rapid emergence of translational developmental neuroscience as the key driver in understanding the onset of mental illness, the restructuring of academic health science centers on the NIH Roadmap, and dramatic shifts in drug, biological, device, and psychosocial intervention development all have important consequences for pediatric anxiety disorders as a field.

METHOD

This article, which tracks the final presentation at a day-long symposium on pediatric anxiety disorders at the 2010 annual meeting of the Anxiety Disorders Association of America (ADAA), will try to outline where the field will head over the next decade as these forces combine to shape research and practice.

RESULTS

After 20 years of large comparative treatment trials that have defined the place of current generation treatments, the field is shifting toward interventions that will emerge from the revolution in translational developmental neuroscience and that herald the dawn of stratified and ultimately personalized medicine. With a much more efficient discovery to translational continuum, intervention development and dissemination will benefit from the concurrent transformation of the clinical and clinical research enterprise.

CONCLUSION

Dramatic advances in science and changes in the structure of medicine will condition the future of clinical research across every therapeutic area in medicine. For the field of pediatric anxiety disorders to thrive it will be important to embrace and actively participate in this revolution so that anxious youth are viewed as a key target population and, consequently, preemptive, preventive, and curative interventions will be developed for children by first intent.

What have we learned about trial design from NIMH-funded pragmatic trials?

At the 2008 annual meeting of the American College of Neuropsychopharmacology (ACNP), a symposium was devoted to the following question: 'what have we learned about the design of pragmatic clinical trials (PCTs) from the recent costly long-term, large-scale trials of psychiatric treatments?' in order to inform the design of future trials. In all, 10 recommendations were generated placing emphasis on (1) appropriate conduct of pragmatic trials; (2) clinical, rather than, merely statistical significance; (3) sampling from the population clinicians are called upon to treat; (4) clinical outcomes of patients, rather than, on outcome measures; (5) use of stratification, controlling, or adjusting when necessary and not otherwise; (6) appropriate consideration of site differences in multisite studies; (7) encouragement of 'post hoc' exploration to generate (not test) hypotheses; (8) precise articulation of the treatment strategy to be tested and use of the corresponding appropriate design; (9) expanded opportunity for training of researchers and reviewers in RCT principles; and (10) greater emphasis on data sharing.

Impact of anxiety disorders on attentional functions in children with ADHD

INTRODUCTION

The impact of internalizing comorbid disorders on cognitive functions in attention-deficit hyperactivity disorder (ADHD) is hardly understood. While inconsistent findings exist with respect to the modulating effect of anxiety on impulsivity in ADHD, only few neuropsychological studies focused on other attention parameters. This is the first study that examines the influence of anxiety disorders (ANX) on ADHD in a model-oriented approach including selectivity and intensity parameters of attention.

METHODS

Children with ADHD, ADHD+ANX and healthy controls (n=34 for each group, all aged 8-15years) participated in five neuropsychological tasks (alertness, sustained attention, divided attention, go/no-go and set-shifting). Group differences were evaluated using analysis of variance (ANOVA) for each dependent variable, with group as independent variable.

RESULTS

Data indicated that children with ADHD performed worse than healthy controls with regard to almost all parameters of attention. While ANX had no mitigating effect on impulsivity in ADHD, performance in sustained attention and selective attention tasks of children with ADHD+ANX was better than that of children with ADHD only.

LIMITATIONS

Since the present data were derived from a large neuropsychological data base which focused primary on children with ADHD and different comorbidities no comparison to a "pure" ANX group was possible.

CONCLUSIONS

These findings might indicate that ADHD+ANX constitute a cognitively distinct subtype, with possible individual symptomatology, development and therapeutic needs. Further investigations are needed to clarify the specificity of these findings and to disentangle the impact of trait versus state anxiety on neuropsychological performance in children with ADHD.

Psychosocial factors associated with parent and teacher reports of aggression in children and adolescents with attention deficit hyperactivity disorder

OBJECTIVE

The prognosis for individuals diagnosed with attention deficit hyperactivity disorder (ADHD) and comorbid aggression is substantially worse than for those with ADHD alone. This study investigates the contribution of key psychosocial factors to both parent and teacher reports of aggressive behaviour in children and adolescents diagnosed with ADHD. It was hypothesized that greater impairment in each would be associated with higher levels of both parent-rated and teacher-rated aggression.

METHOD

Information collected during semi-structured clinical interviews from 676 boys and girls aged 6 to 16 and diagnosed with ADHD was analysed. Measures of potential psychosocial factors including parental psychopathology, family functioning, marital relationship quality and child interpersonal relationship status were administered. Ratings of aggression were obtained from both parents and teachers, and the association of psychosocial measures for each were separately analysed.

RESULTS

Correlation and multiple regression analyses revealed significant associations between parent-rated aggression and measures of increased parent psychopathology, decreased family function and deficient child interpersonal relationships. Teacher-rated aggression was only associated with deficient child interpersonal relationships.

CONCLUSION

The findings highlight important differences in the psychosocial factors that contribute to parent and teacher ratings of aggression in the context of ADHD. The implications of these findings for both the clinician and researcher are discussed.

Ethnicity as a moderator of treatment effects on parent--child interaction for children with ADHD

OBJECTIVE

To examine ethnic differences in observed parenting and child behavior and the moderating effects of ethnicity on the relationship between treatment and parent and child behavior.

METHOD

Observations of 508 children with ADHD (ages 7-9) and their caregivers, collected during the Multimodal Treatment Study of ADHD, were analyzed using univariate and mixed-model ANOVAs.

RESULTS

Although baseline parenting practices differed by ethnic group, ethnicity did not moderate the relationship between treatment and either parenting or child behavior.

CONCLUSION

Consistent with data from normative samples, parents of children with ADHD differed by ethnicity in their utilization of certain parenting strategies. However, different ethnic groups did not differ on benefit received from treatments for ADHD, measured by parent and child behavior. Although ethnicity did not emerge as a moderator, ethnic minority family engagement in treatment may be increased by recognizing different parenting strategies and modifying interventions accordingly.

Clinical response to methylphenidate in children diagnosed with attention-deficit hyperactivity disorder and comorbid psychiatric disorders

OBJECTIVE

To determine to what extent the clinical response to methylphenidate (MPH) is affected by psychiatric comorbidities in children diagnosed with attention-deficit hyperactivity disorder (ADHD).

METHODS

Children (n = 267) aged 6 to 12 years diagnosed with ADHD participated in a double-blind, placebo-controlled, 2-week medication trial of MPH. Children were assessed using parent and teacher ratings and laboratory measures. Clinical response to MPH was determined by integrating all obtained measures.

RESULTS

Meeting criteria for conduct disorder (CD) was 27.7% of children, 40.8% for oppositional defiant (ODD), 47.2% for anxiety, and 7.9% for depressive disorders. The presence of CD or ODD was associated with good response to MPH. In contrast, children diagnosed with only comorbid anxiety were more likely to receive poor response rating independent of age, sex, or socioeconomic status. Low family income was found to be predictive of good response to MPH.

CONCLUSIONS

The response to MPH in children with ADHD may be dependent on the type of comorbid disorder present.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00483106.

Clinical characteristics of anxiety disordered youth

Reports the characteristics of a large, representative sample of treatment-seeking anxious youth (N=488). Participants, aged 7-17 years (mean 10.7 years), had a principal DSM-IV diagnosis of separation anxiety disorder (SAD), generalized anxiety disorder (GAD), or social phobia (SP). Although youth with a co-primary diagnosis for which a different disorder-specific treatment would be indicated (e.g., major depressive disorder, substance abuse) were not included, there were few other exclusion criteria. Participants and their parent/guardian underwent an extensive baseline assessment using a broad array of measures capturing diagnostic status, anxiety symptoms and severity, and areas of functional impairment. Means and standard deviations of the measures of psychopathology and data on diagnostic status are provided. The sample had moderate to severe anxiety disorder and was highly comorbid, with 55.3% of participants meeting criteria for at least one non-targeted DSM-IV disorder. Anxiety disorders in youth often do not present as a single/focused disorder: such disorders in youth overlap in symptoms and are highly comorbid among themselves.

The moderating role of sensory Overresponsivity in HPA activity: a pilot study with children diagnosed with ADHD

OBJECTIVE

To determine if sensory overresponsivity (SOR) is a moderating condition impacting the activity of the Hypothalamic Pituitary Adrenal (HPA) Axis in children with ADHD.

METHOD

Participants were children with (n = 24) and without ADHD (n = 24). Children in the ADHD group were divided into SOR (ADHDs) and non-SOR (ADHDt) groups using the Sensory Over-Responsivity Inventory. All children participated in the Sensory Challenge Protocol. Salivary cortisol was used as a measure of HPA activity. Two prechallenge and seven postchallenge samples of saliva were taken. Cortisol patterns between groups were examined using a mixed-effects ANOVA.

RESULTS

There was a borderline significant difference found between the ADHDt and ADHDs group (p = .056) and a significant difference between ADHDt and the typical group (p = .014).

CONCLUSION

Preliminary results support the premise that SOR may be a moderating variable used to create subgroups in diagnostic populations such as ADHD. (J. of Att. Dis. 2010; 13(5) 468-478).

Packages of care for attention-deficit hyperactivity disorder in low- and middle-income countries

In the sixth in a series of six articles on packages of care for mental disorders in low- and middle-income countries, Alan Flisher and colleagues discuss the treatment of attention-deficit hyperactivity disorder.

Predicting response of ADHD symptoms to methylphenidate treatment based on comorbid anxiety

OBJECTIVE

In this small pilot study, the association of comorbid anxiety with the treatment of ADHD is studied.

METHODS

Eighteen volunteers from a pediatric clinic are tested for ADHD and anxiety and assessed for behavioral and cognitive ADHD symptomology. Response to methylphenidate as treatment for ADHD symptoms is measured 2 to 3 weeks, and again 4 to 6 weeks following the diagnosis of ADHD.

RESULTS

Methylphenidate proves effective for treating ADHD symptoms (both behavioral and cognitive). Participants are categorized into two groups, those with ADHD and comorbid anxiety and those with ADHD alone. Behaviorally, no statistically significant differences are seen in response between the two groups; however; cognitively, the non-anxious group improves significantly more than the anxious group.

CONCLUSION

Although anxiety may not affect behavioral response to stimulant medication in ADHD, it does appear to affect the medication response of more subtle symptoms of cognitive performance in ADHD patients.

Issues in the management of patients with complex attention-deficit hyperactivity disorder symptoms

Patients with attention-deficit hyperactivity disorder (ADHD) exhibit a wide range of symptoms related to functional impairment. Psychiatric comorbidities are highly prevalent among these patients, often emerging at an early age and persisting (or reoccurring) into adulthood. Among the most common types of comorbidities in children and adults are disruptive behaviour disorders such as oppositional defiant disorder and conduct disorder, mood disorders, anxiety disorders, and substance use disorders. The heterogeneous clinical presentation of ADHD, which also changes with maturation into adulthood, may often obscure the presence of psychiatric comorbidity. Co-occurring disorders frequently go undetected and lead to negative effects on psychosocial and long-term functional outcomes. As with uncomplicated ADHD, medication therapy combined with psychosocial interventions may be necessary. With comorbid disorders, two or more medications may be considered to appropriately manage both ADHD and the comorbid disorder. However, there are few studies that discuss combination medication treatments and there are no current US FDA-approved combined treatments for ADHD and comorbid conditions. This raises significant challenges and risks for poor tolerability and drug-drug interactions. Nevertheless, identification and appropriate treatment must be given a high priority for these highly vulnerable patients to derive optimal benefits from treatment.

Use of atomoxetine in patients with attention-deficit hyperactivity disorder and co-morbid conditions

Attention-deficit hyperactivity disorder (ADHD) is one of the most common neurobehavioural disorders in children. It has been shown that as many as 85% of patients with ADHD have at least one psychiatric co-morbidity, and approximately 60% have at least two. Atomoxetine is a specific, noradrenergic reuptake inhibitor that provides an effective treatment option for patients with ADHD and co-morbid conditions. The efficacy of atomoxetine in treating ADHD appears to be unaffected by the presence of co-morbid conditions. Therapy with atomoxetine has been associated with statistically significant improvements in symptoms of oppositional defiant disorder in most, but not all, studies. Limited data suggest this agent may have potential in improving co-occurring symptoms of anxiety and may be useful in patients with co-morbid conditions such as tics or Tourette's syndrome. The tolerability profile of atomoxetine in patients with ADHD and co-morbid conditions was similar to that of patients with uncomplicated ADHD. Atomoxetine was well tolerated, with adverse events generally mild and transient; the most frequent adverse events in patients with ADHD included abdominal pain, decreased appetite, nausea and vomiting. The favourable safety and efficacy profile of atomoxetine makes it a promising treatment for patients with ADHD and associated co-morbidities.

Dopamine transporter genotype and stimulant side effect factors in youth diagnosed with attention-deficit/hyperactivity disorder

The dopamine transporter locus (DAT1) has been studied as a risk factor for attention-deficit/hyperactivity disorder (ADHD) and in pharmacogenetic studies of stimulant response. Several prospective studies have reported an association between the homozygous 9 repeat allele of the DAT1 3' untranslated region (UTR) variable number tandem repeat (VNTR) (DAT1 3') and decreased efficacy of methylphenidate (MPH). We hypothesized that children with the 9/9 genotype would display higher rates of specific stimulant side effects. Data on adverse events and DAT1 3' genotypes were combined from two, double-blind, placebo-controlled, crossover studies of MPH conducted in child psychiatric outpatient clinics in Montreal and Washington, D.C. There were 177 participants, 5-16 years old (mean age = 8.99, standard deviation [SD] = 2), with ADHD. Parents completed the Stimulant Side Effect Scale (SERS) after a week of placebo and a week of MPH treatment. Principal components analysis of the SERS resulted in three factors: Emotionality, Somatic Complaints, and Over-focused. Children with the 9/9 genotype displayed higher scores on the Emotionality factor during placebo than children with the 9/10 and the 10/10 genotype, and their Emotionality scores increased further during MPH treatment (F[2,151] = 3.24, p < 0.05). Children with the 10/10 genotype displayed a significant increase in Somatic Complaint factor scores during MPH treatment relative to the other genotype groups (F[2,150] = 3.4, p < 0.05). These data provide suggestive evidence that DAT1 variants are differentially associated with specific stimulant side effects. Children with the 9/10 genotype displayed less severe stimulant side-effect ratings than either of the homozygous groups, who each displayed increased susceptibility to different types of adverse events. Preliminary evidence suggests that pharmacogenetic analysis using DAT1 variants shows promise for identifying individuals at increased or decreased risk for poor tolerability.

Clinical responses to atomoxetine in attention-deficit/hyperactivity disorder: the Integrated Data Exploratory Analysis (IDEA) study

OBJECTIVE

Clinical experience suggests that some (but not all) patients with attention-deficit/hyperactivity disorder (ADHD) are highly responsive to the nonstimulant atomoxetine. We conducted a retrospective analysis of randomized controlled trials (RCTs) to identify potential baseline (moderator) and on-treatment (mediator) predictors of responses.

METHOD

Data from 6 U.S. RCTs among patients aged 6 to 18 years were pooled (N = 1,069; subjects treated with atomoxetine, n = 618). Subjects were categorized as much improved (> or = 40% decrease in ADHD Rating Scale-IV-Parent Version: Investigator Administered and Scored total score), minimally improved (25%-< 40% decline), or nonresponders (< 25% decrease). Logistic regression, analyses of variance, and repeated-measures analyses were used to explore associations between baseline and on-treatment variables, achieving a much improved response at trial endpoint (6-9 weeks).

RESULTS

Forty-seven percent of patients showed a much improved clinical response, and 40% did not respond. Only 13% of the patients had a minimal response. No baseline characteristics predicted achieving a much improved clinical response; the only predictor of achieving this response was being at least minimally improved by treatment week 4 (sensitivity = 81%, specificity = 72%, positive predictive value = 75%, and negative predictive value = 79%).

CONCLUSIONS

Clinical response to atomoxetine was bimodal, with most subjects being either responders who were much improved or nonresponders. There were no demographic or clinical predictors of response. However, subjects who ultimately achieved a much improved response were likely to be at least minimal responders by week 4. The recommendation to consider either augmenting or switching treatment in patients who do not achieve at least this level of response to atomoxetine by 4 weeks offers a method for limiting the extended duration of titration to subjects who are most likely to benefit further, while minimizing the duration of exposure in those less likely to achieve an excellent response.

How often do children meet ICD-10/DSM-IV criteria of attention deficit-/hyperactivity disorder and hyperkinetic disorder? Parent-based prevalence rates in a national sample--results of the BELLA study

BACKGROUND

There is a lack of representative prevalence rates for attention deficit-/hyperactivity disorder (ADHD) according to DSM-IV criteria and hyperkinetic disorder (HD) according to ICD-10 criteria for German subjects.

OBJECTIVE

To report the results of analyses of categorical data on the prevalence rates of the symptoms of ADHD/HD and additional diagnostic criteria, as well as of the diagnoses of ADHD and HD according to symptoms and other diagnostic criteria, according to the ICD-10 and DSM-IV. Further, to report administrative prevalence rates of the diagnosis and rates of co-existing behavioural and emotional problems.

METHOD

Within the BELLA module of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), a representative sample of parents of 2,452 children and adolescents aged 7-17 years completed an ADHD symptom checklist (FBB-HKS/ADHS) and additional questionnaires for the assessment of coexisting behavioural and emotional problems.

RESULTS

The prevalence rates for the diagnoses of ADHD according to DSM-IV criteria were 5.0% and the rate for HD according to ICD-10 criteria was 1.0%. Higher prevalence rates were found in boys and in younger children. The addition of other diagnostic criteria (impairment, pervasiveness, onset, duration) resulted in a significant decrease of the prevalence rates of ADHD and HD to 2.2 and 0.6%, respectively. Higher prevalence rates were found in families of lower socioeconomic status and families from urban areas. The lifetime administrative prevalence rate was 6.5%. Children with ADHD had an increased risk for coexisting behavioural and emotional problems, especially for aggressive and antisocial behaviour problems, but also for anxiety and mood problems.

CONCLUSION

The results of the national sample are in line with community studies in other countries. The effects of the additional diagnostic criteria of impairment, situational pervasiveness, symptom onset and symptom duration on the prevalence rates have to be considered in other epidemiological studies.

Child anxiety disorders in public systems of care: comorbidity and service utilization

Little is known about mental health service use among children with anxiety disorders, and even less is known about these children in public sectors of care. In this study, 1,715 children were randomly sampled from one of five public service systems. Psychiatric diagnoses were assessed with a structured interview, and standardized measures were used to assess mental health service utilization. Data from a subsample (n = 779) of youth with psychiatric disorders were analyzed. Analyses revealed that comorbidity among children with anxiety disorders was substantially higher than general population estimates. Approximately 26% of children with anxiety had a comorbid mood disorder, and 62% had a disruptive behavior disorder. Among children with anxiety disorders, those who had comorbid conditions were more likely to receive inpatient services than those without comorbidity. Comorbidity, caregiver strain, and service sector were associated with inpatient and nonspecialty service use in this group. Findings underscore the substantial comorbidity among children with anxiety disorders in public sectors of care and the potential need to adapt evidence-based interventions to meet the complex and multiple needs of these children.

Treatment of attention deficit hyperactivity disorder in children. Predictors of treatment outcome

OBJECTIVE

The present study investigated the predictive power of anxiety, IQ, severity of ADHD and parental depression on the outcome of treatment in children with ADHD.

METHOD

Fifty children with ADHD (ages 8-12) were randomized to a 10-week treatment of methylphenidate or to a treatment of methylphenidate combined with multimodal behavior therapy. Prior to treatment predictors were assessed. Outcome was assessed separately for parents and teachers on a composite measure of inattentive, hyperactive, oppositional- and conduct disorder symptoms.

RESULTS

There was neither a significant difference between the two treatments at baseline nor did treatment condition predict outcome. Therefore the data were collapsed across the two treatments. A combination of anxiety and IQ predicted teacher-rated outcome, explaining 18% of the variance. Higher anxiety and higher IQ's indicated better treatment outcome. There were no significant predictors of the parent-rated outcome.

CONCLUSION

This study showed a small but significant predictive effect of IQ and anxiety on treatment outcome in children with ADHD.

CLINICAL IMPLICATIONS

This study supports the idea that for the treatment of ADHD children with comorbid anxiety and higher IQ respond better to the two most used treatments for ADHD.

Nature of anxiety comorbid with attention deficit hyperactivity disorder in children from a pediatric primary care setting

The clinical characteristics of children with comorbid anxiety and attention deficit hyperactivity disorder (ADHD were examined. A sample of children from a pediatric primary care practice was assessed for anxiety disorders and ADHD. We defined four groups of children: (1) anxiety disorders only with no ADHD (n=54); (2) ADHD-only with no anxiety disorder (n=15); (3) neither ADHD nor an anxiety disorder (n=107); and (4) comorbid ADHD and anxiety disorder (n=14). Approximately 50% of children with ADHD had a comorbid anxiety disorder, and approximately 20% of children with an anxiety disorder had comorbid ADHD. The presence of comorbid ADHD and anxiety was associated with more attentional problems, school fears, and mood disorders and lower levels of social competence compared to children who had either ADHD-only or anxiety-only. Children with comorbid anxiety disorders and ADHD have more severe symptoms and are more impaired than children with either condition alone. Interventions need to be tailored to address the complexity of these comorbid conditions and their associated sequelae.

Characterizing non-OCD anxiety disorders in psychiatrically referred children and adolescents

BACKGROUND

To characterize childhood and adolescent anxiety disorders in a psychiatric clinic.

METHODS

Subjects were 1375 youth referred to a pediatric psychopharmacology program at a major academic center from 1991-2002. DSM-III-R diagnoses were obtained by Schedule for Affective Disorders and Schizophrenia for School-Age Children.

RESULTS

Of 1375 referred youth, 794 had at least one non-obsessive-compulsive anxiety disorder, and 581 psychiatric comparison subjects had at least one disruptive behavior disorder and no anxiety disorders. There were 367 (46%) youth with one anxiety disorder, 224 (28%) with two disorders. Most prevalent were separation anxiety (49%), and overanxious disorder (47%). Mean ages of onset ranged from simple phobia (4.1) to panic disorder (8.5). Risk analyses revealed anxiety disorders significantly increased risk for anxiety and mood disorders.

CONCLUSIONS

The full complement of anxiety disorders occurs in youth.