Long-term stimulant treatment of children with attention-deficit hyperactivity disorder symptoms. A randomized, double-blind, placebo-controlled trial

A double-blind, placebo-controlled withdrawal trial of dexmethylphenidate hydrochloride in children with attention deficit hyperactivity disorder

OBJECTIVES

d,l-threo-methylphenidate HCl (D,L-MPH) is the most common treatment of attention deficit hyperactivity disorder (ADHD). A previous report showed placebo-controlled efficacy for the purified d-isomer (dexmethylphenidate hydrochloride, d-MPH, Focalin) with a 2:1 potency compared to dl, and suggested a 6-hour duration of action. This study complements that report by studying the effect of placebo-controlled discontinuation and retesting the duration of action.

METHODS

A 6-week, open-label titration of d-MPH (2.5-10 mg twice-a-day) was followed by a double-blind, placebo-controlled, 2-week withdrawal study of responders.

RESULTS

In the open titration, 82% of the 89 enrolled patients achieved a Clinical Global Impression-Improvement (CGI-I) rating of much or very much improved. Only 5 patients discontinued for adverse events. Seventy-five patients continued into the placebo-controlled discontinuation. For the randomly assigned d-MPH (n=35) and placebo (n=40) groups, mean ages, respectively, were 10.1 +/- 2.9 and 9.9 +/- 2.7 years, 86% and 78% were male, and 70.6% and 80.0% took the ceiling dose of 10 mg twice-daily, respectively. Each group had 80% combined type ADHD and 20% inattentive type. By the end of the 2-week, placebo-masked withdrawal, significantly more placebo patients (24 of 39) than d-MPH continuers (6 of 35) relapsed (61.5% versus 17.1%, p=0.001). Compared to d-MPH continuers, placebo patients deteriorated significantly more in the 2-week period on teacher ratings of the 18 ADHD symptoms rated 0-3 (p=0.028), the 3 p.m. and 6 p.m. parent ADHD symptom ratings (p=0.0026 and p=0.0381, respectively), and clinic (2-3 p.m.) and home (6 p.m.) Math Tests (p=0.024 and p<0.0001, respectively). The 6 p.m. scores replicated the significant effect at 6 hours reported in the previous study.

CONCLUSIONS

d-MPH is safe, tolerable, and effective, with a 6-hour duration of effect suggested by the significant difference from placebo at 6 hours on a double-blind discontinuation.

Dyssomnia in children diagnosed with attention deficit hyperactivity disorder: a critical review

OBJECTIVE

Studies prior to 1999 reported prevalent sleep disturbances in children diagnosed with attention deficit hyperactivity disorder (ADHD). However, these reports were largely inconclusive and inconsistent in their findings, hence the current review based on studies published thereafter.

METHOD

An online research of the National Library of Medicine and the Cochrane Library was conducted using the terms 'attention deficit hyperactivity disorder', 'sleep', 'human', and 'English language'.

RESULTS

Sixteen articles met the search criteria with 10 reporting objective measures of sleep characteristics (i.e. polysomnography, actigraphy, and/or video recording). These studies confirm an increase of rapid eye movement (REM) sleep latency and a proportional decrease of REM sleep in children diagnosed with ADHD. Stimulant treatment appears to have little effect on sleep quality while parent's reports of poor sleep in their ADHD-diagnosed offspring was largely inconsistent with the objective measures.

CONCLUSIONS

The review demonstrated a link between disturbances in sleep architecture and ADHD. Whether this is of an intrinsic or extrinsic cause remains debateable, as both behavioural (parental reporting) and physiological (objective differences in sleep architecture) factors are indicated. The effect of stimulant medication on sleep also requires further research, as current evidence is limited by study design.

Review and comparison of the long acting methylphenidate preparations

The stimulants have been the mainstay of pharmacologic treatment for over fifty years. Methylphenidate is the most frequently prescribed of the stimulant agents. In the past, one of the main drawbacks of these agents was the abbreviated duration of action. Over the last few years three longer acting methylphenidate preparations have been released to the market. Though all these agents contain the same chemical compound they do vary in a number of ways. In this article we will present how the formulations compare in their technology and the differences in their delivery systems. We will also compare the available literature that focus on head to head comparisons in terms of pharmacokinetics studies and those reports that present efficacy data. Finally, we will suggest based on a theoretical framework on how to approach selecting an agent based on the results of these trials and the individual needs of the patient.

Co-existing disorders in ADHD -- implications for diagnosis and intervention

BACKGROUND

It is only recently that "comorbidity" in ADHD has come to the forefront as one of the most important aspects of the disorder. It is agreed that, often, these problems are at least as important as ADHD in contributing to the longer term outcome in the individual child.

OBJECTIVE

To provide the reader with basic information about clinics and treatment of "comorbidity" in ADHD.

METHOD

Review of the empirically based literature.

RESULTS

ADHD exists in a surprisingly high frequency together with a broad range of child neuropsychiatric disorders. This is accompanied with many still unresolved treatment problems.

CONCLUSION

It would not be appropriate to develop ADHD-services where clinicians would only have expertise in ADHD as such. Anyone working with children, adolescents and adults with ADHD would need to have training in general neuropsychiatry. Further research in this field is urgently needed.

New formulations of stimulants for attention-deficit hyperactivity disorder: therapeutic potential

New formulations of stimulant medications for the treatment of attention-deficit hyperactivity disorder (ADHD) have been an important focus for pharmaceutical industry research and development over the past decade. In this article, we review and assess the therapeutic potential of five new stimulant formulations (one immediate release and four longer-acting preparations) that have recently become available for the treatment of ADHD. While the therapeutic potential of immediate-release enantiomers of methylphenidate has not yet been clinically realised, new long-acting formulations of stimulants have changed the standard of care for children, adolescents and adults with ADHD. The longer duration of action of these once-daily compounds, and the consequent expansion of the duration of daily ADHD coverage afforded by them, has introduced the realistic possibility of reducing the overall daily burden of ADHD on affected individuals. Although more expensive, these new stimulant formulations are easier for patients to use than older stimulants, more resistant to abuse and misuse, and allow for increased privacy of ADHD treatment at school or work.

Prevalence of bruxism in children receiving treatment for attention deficit hyperactivity disorder: a pilot study

The objective of this study was to evaluate reported bruxism among children affected by attention deficit hyperactivity disorder (ADHD). Thirty children diagnosed with ADHD and 30 healthy age and gender matched controls participated in the study. All subjects were examined for dental attrition, and the parents were asked for signs and symptoms of bruxism in their children using a questionnaire. Prevalence of oral parafunction was evaluated comparing ADHD children taking medications, ADHD children not taking medications, and controls. Subjects affected by ADHD and pharmacologically treated showed higher occurrence of bruxism compared to subjects affected by ADHD not taking medicines and controls; and within the ADHD group taking medications, CNS-stimulants have been associated with such side effect more frequently than the other drugs.

Cost-effectiveness of dexamphetamine and methylphenidate for the treatment of childhood attention deficit hyperactivity disorder

OBJECTIVE

To analyze from a health sector perspective the cost-effectiveness of dexamphetamine (DEX) and methylphenidate (MPH) interventions to treat childhood attention deficit hyperactivity disorder (ADHD), compared to current practice.

METHOD

Children eligible for the interventions are those aged between 4 and 17 years in 2000, who had ADHD and were seeking care for emotional or behavioural problems, but were not receiving stimulant medication. To determine health benefit, a meta-analysis of randomized controlled trials was performed for DEX and MPH, and the effect sizes were translated into utility values. An assessment on second stage filter criteria ("equity", "strength of evidence", "feasibility" and "acceptability to stakeholders") is also undertaken to incorporate additional factors that impact on resource allocation decisions. Simulation modelling techniques are used to present a 95% uncertainty interval (UI) around the incremental cost-effectiveness ratio (ICER), which is calculated in cost (in A$) per DALY averted.

RESULTS

The ICER for DEX is A$4100/DALY saved (95% UI: negative to A$14 000) and for MPH is A$15 000/DALY saved (95% UI: A$9100-22 000). DEX is more costly than MPH for the government, but much less costly for the patient.

CONCLUSIONS

MPH and DEX are cost-effective interventions for childhood ADHD. DEX is more cost-effective than MPH, although if MPH were listed at a lower price on the Pharmaceutical Benefits Scheme it would become more cost-effective. Increased uptake of stimulants for ADHD would require policy change. However, the medication of children and wider availability of stimulants may concern parents and the community.

Social functioning in children with ADHD treated with long-term methylphenidate and multimodal psychosocial treatment

OBJECTIVE

To test that methylphenidate combined with intensive multimodal psychosocial intervention, which includes social skills training, significantly enhances social functioning in children with attention-deficit/hyperactivity disorder (ADHD) compared with methylphenidate alone and methylphenidate plus nonspecific psychosocial treatment (attention control).

METHOD

One hundred three children with ADHD (ages 7-9), free of conduct and learning disorders, who responded to short-term methylphenidate were randomized for 2 years to receive (1) methylphenidate alone, (2) methylphenidate plus multimodal psychosocial treatment that included social skills training, or (3) methylphenidate plus attention control treatment. Assessments included parent, child, and teacher ratings of social function and direct school observations in gym.

RESULTS

No advantage was found on any measure of social functioning for the combination treatment over methylphenidate alone or methylphenidate plus attention control. Significant improvement occurred across all treatments and continued over 2 years.

CONCLUSIONS

In young children with ADHD, there is no support for clinic-based social skills training as part of a long-term psychosocial intervention to improve social behavior. Significant benefits from methylphenidate were stable over 2 years.

Relapse prevention in pediatric patients with ADHD treated with atomoxetine: a randomized, double-blind, placebo-controlled study

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) is typically treated over extended periods; however, few placebo-controlled, long-term studies of efficacy have been reported.

METHOD

In a global multicenter study, children and adolescents who responded to an initial 12-week, open-label period of treatment with atomoxetine, a nonstimulant treatment for ADHD, were randomized to continued atomoxetine treatment or placebo for 9 months under double-blind conditions.

RESULTS

A total of 416 patients completed acute atomoxetine treatment and were randomized. At end point, atomoxetine was superior to placebo in preventing relapse defined as a return to 90% of baseline symptom severity (proportion relapsing: atomoxetine 65 of 292 [22.3%], placebo 47 of 124 [37.9%], p =.002). The proportion of patients with a 50% worsening in symptoms post-randomization was also lower on atomoxetine (atomoxetine 83 of 292 [28.4%], placebo 59 of 124 [47.6%], p <.001). Compared with patients in the placebo group, atomoxetine-treated patients had superior psychosocial functioning at end point. Discontinuations for adverse events were low in both groups, and tolerability was similar to that observed in acute treatment trials.

CONCLUSIONS

In patients who responded favorably to 12 weeks of initial treatment, atomoxetine was superior to placebo in maintaining response for the ensuing 9 months. This result supports the value of maintenance treatment with atomoxetine in patients with ADHD who respond to initial treatment.

Stimulant treatment over five years: adherence, effectiveness, and adverse effects

OBJECTIVE

To evaluate the impact of adherence and medication status on effectiveness and adverse effects of stimulant use in children with attention-deficit/hyperactivity disorder (ADHD) over 5 years.

METHOD

Seventy-nine of 91 participants in a 12-month randomized controlled trial of methylphenidate and parent groups enrolled in a follow-up study. Adherence to stimulants, treatment response, and adverse effects were evaluated annually for 5 years. Changes in teacher-reported symptoms and parent-reported adverse effects were compared at 2, 3, 4, and 5 years for 3 groups: adherents, nonadherents on medication, or nonadherents off medication. Controlling for age, gender, and baseline severity, adherence status and medication status were evaluated as correlates of teacher-reported ADHD symptom scores at each year using multiple regression analyses.

RESULTS

At 2 years, adherents (n = 41) showed greater improvement in teacher-reported symptoms than those off medication (n = 16) and equivalent response to nonadherents on stimulants (n = 16) (p =.02). At 5 years, adherents (n = 16) showed greater improvement in teacher-reported symptoms than nonadherents on stimulants (n = 15) and those off medication (n = 14) (p =.04). At year 2 medication status (beta = 4.67 [0.40-8.95, p =.033]) and at year 5 adherence status (beta = 7.23 [3.01-11.44, p =.001]) correlated with higher teacher-reported symptom scores. Clinically significant adverse effects were present for 5 years, most commonly loss of appetite.

CONCLUSIONS

Psychostimulants improve ADHD symptoms for up to 5 years, but adverse effects persist.

Zinc sulfate as an adjunct to methylphenidate for the treatment of attention deficit hyperactivity disorder in children: a double blind and randomized trial [ISRCTN64132371]

BACKGROUND

Attention-deficit hyperactivity disorder is an early-onset, clinically heterogenous disorder of inattention, hyperactivity, and impulsiveness. The diagnosis and treatment of attention-deficit hyperactivity disorder continues to raise controversy, and, there is also an increase in treatment options. In this 6-week double blind, placebo controlled-trial, we assessed the effects of zinc plus methylphenidate in the treatment of children with attention deficit hyperactivity disorder. To the best of our knowledge, this study is the first double blind and placebo controlled clinical trial assessing the adjunctive role of zinc in ADHD.

METHODS

Our subjects were 44 outpatient children (26 boys and 18 girls) between the ages of 5-11 (mean +/- SD was 7.88 +/- 1.67) who clearly met the DSM IV diagnostic criteria for attention-deficit hyperactivity disorder and they were randomized to methylphenidate 1 mg/kg/day + zinc sulfate 55 mg/day (with approximately 15 mg zinc element) (group 1) and methylphenidate 1 mg/kg/day + placebo (sucrose 55 mg) (group 2) for a 6 week double blind clinical trial. The principal measure of the outcome was the Teacher and Parent ADHD Rating Scale. Patients were assessed by a child psychiatrist at baseline, 14, 28 and 42 days after the medication started.

RESULTS

The present study shows the Parent and Teacher Rating Scale scores improved with zinc sulfate over this 6-week, double blind and placebo controlled trial. The behavior of the two treatments was not homogeneous across the time. The difference between the two protocols was significant as indicated by the effect on the group, the between-subjects factor (F = 4.15, d.f. = 1, P = 0.04; F = 4.50, d.f. = 1, P = 0.04 respectively). The difference between the two groups in the frequency of side effects was not significant.

CONCLUSIONS

This double-blind, placebo-controlled study demonstrated that zinc as a supplementary medication might be beneficial in the treatment of children with attention-deficit hyperactivity disorder. However, further investigations and different doses of zinc are required to replicate these findings in children with ADHD.

National Institute of Mental Health Multimodal Treatment Study of ADHD follow-up: changes in effectiveness and growth after the end of treatment

OBJECTIVE

Intent-to-treat analyses of the Multimodal Treatment Study of ADHD (MTA) revealed group differences on attention-deficit/hyperactivity disorder symptoms ratings, with better outcome in groups of participants who were assigned the medication algorithm-medication alone (MedMgt) and combined (Comb)--than in those who were not-behavior modification (Beh) alone and community comparison (CC). However, the effect size was reduced by 50% from the end of treatment to the first follow-up. The convergence of outcomes suggests differential changes by treatment group beween 14 and 24 months, which this report explores, both for benefits of treatment and for side effects on growth.

METHODS

We documented reported medication use at 14- and 24-month assessments and formed 4 naturalistic subgroups (Med/Med, Med/NoMed, NoMed/Med, and NoMed/NoMed). Then we performed exploratory mediator analyses to evaluate effects of changes in medication use on 14- to 24-month change scores of effectiveness (symptom ratings) and growth (height and weight measures).

RESULTS

The randomly assigned groups with the greatest improvement at the end of the treatment phase (Comb and MedMgt) deteriorated during the follow-up phase, but the other 2 groups (Beh and CC) did not. There were no significant differences in the 14- to 24-month growth rates among the randomly assigned groups, in contrast to significant growth suppression in the Comb and MedMgt at the end of the treatment phase. Changes in medication use mediated the 14- to 24-month change in attention-deficit/hyperactivity disorder symptom ratings: the subgroup that reported stopping medication (Med/NoMed) showed the largest deterioration, the subgroup that consistently reported (Med/Med) or never reported (NoMed/NoMed) medication use showed modest deterioration, and the subgroup that reported starting medication (NoMed/Med) showed improvement. Changes in medication use also mediated growth effects: the subgroup that consistently reported medication use (Med/Med) showed reduced height gain compared with the subgroup that never reported medication use (NoMed/NoMed), which actually grew faster than predicted by population norms.

CONCLUSION

In the MTA follow-up, exploratory naturalistic analyses suggest that consistent use of stimulant medication was associated with maintenance of effectiveness but continued mild growth suppression.

Efficacy of theophylline compared to methylphenidate for the treatment of attention-deficit hyperactivity disorder in children and adolescents: a pilot double-blind randomized trial

Attention-deficit hyperactivity disorder (ADHD) is a common disorder of childhood that affects 3-6% of school children. Conventional stimulant medications are recognized as useful symptomatic treatments by both specialists and parents. Nevertheless, approximately 30% of ADHD children treated with them do not respond adequately or cannot tolerate the associated adverse effects. Such difficulties highlight the need for alternative, safe and effective medications in the treatment of this disorder. Theophylline is a psychomotor stimulant most widely used as a broncodilator. Purinergic modulation may be therapeutically beneficial in the treatment of psychiatric disorders. We hypothesized that theophylline would be beneficial for the treatment of ADHD and report results of a trial of theophylline compared with methylphenidate for the treatment of ADHD. A total of 32 children with ADHD as defined by DSM IV were randomized to theophylline and methylphenidate dosed on an age and weight-adjusted basis at 4 mg/kg/day (under 12 years) and 3 mg/kg/day theophylline (over 12 years) (group 1) and 1 mg/kg/day methylphenidate (group 2) for a 6-week double-blind and randomized clinical trial. The principal measure of the outcome was the Teacher and Parent ADHD Rating Scale. Patients were assessed by a child psychiatrist, at baseline and at 14, 28 and 42 days after start of the medication. No significant differences were observed between theophylline and methylphenidate on the Parent and Teacher Rating Scale scores over the trial (t = 0.49, d.f. = 24 P = 0.62 and t = 0.19, d.f. = 24 P = 0.54 respectively). Although the number of dropouts in the methylphenidate group was higher than the theophylline group, there was no significant difference between the two protocols in terms of the dropouts. In addition, headaches were observed more often in the methylphenidate group. The results suggest that theophylline may be a useful for the treatment of ADHD. In addition, a tolerable side-effect profile is one of the advantages of theophylline in the treatment of ADHD. Nevertheless, our study is small and our results would need to be confirmed in a larger study.

National Institute of Mental Health Multimodal Treatment Study of ADHD follow-up: 24-month outcomes of treatment strategies for attention-deficit/hyperactivity disorder

OBJECTIVE

In the Multimodal Treatment Study of ADHD (MTA), the effects of medication management (MedMgt) and behavior modification therapy (Beh) and their combination (Comb) and usual community comparison (CC) in the treatment of attention-deficit/hyperactivity disorder (ADHD) differed at the 14-month assessment as a result of superiority of the MTA MedMgt strategy (Comb or MedMgt) over Beh and CC and modest additional benefits of Comb over MedMgt alone. Here we evaluate the persistence of these beneficial effects 10 months beyond the 14 months of intensive intervention.

METHODS

Of 579 children who entered the study, 540 (93%) participated in the first follow-up 10 months after the end of treatment. Mixed-effects regression models explored possible persisting effects of the MTA medication strategy, the incremental benefits of Comb over MedMgt alone, and the possible superiority of Beh over CC on 5 effectiveness and 4 service use domains.

RESULTS

The MTA medication strategy showed persisting significant superiority over Beh and CC for ADHD and oppositional-defiant symptoms at 24 months, although not as great as at 14 months. Significant additional benefits of Comb over MedMgt and of Beh over CC were not found. The groups differed significantly in mean dose (methylphenidate equivalents 30.4, 37.5, 25.7, and 24.0 mg/day, respectively). Continuing medication use partly mediated the persisting superiority of Comb and MedMgt.

CONCLUSION

The benefits of intensive MedMgt for ADHD extend 10 months beyond the intensive treatment phase only in symptom domains and diminish over time.

Long-term use of stimulants in children with attention deficit hyperactivity disorder: safety, efficacy, and long-term outcome

The purpose of this review is to summarize existing data on the long-term safety and efficacy of stimulant treatment, and how long-term stimulant treatment of children with attention deficit hyperactivity disorder (ADHD) affects their outcome. Existing controlled studies of children with ADHD treated and untreated with stimulants, as well as long-term prospective follow-up studies, are reviewed. Children with ADHD treated with stimulants for as long as 2 years continue to benefit from the treatment, with improvements observed in ADHD symptoms, comorbid oppositional defiant disorder, and academic and social functioning, with no significant problems of tolerance or adverse effects. Long-term, prospective follow-up studies into adulthood show that stimulant treatment in childhood has slight benefits regarding social skills and self-esteem. Long-term adverse effects from stimulant treatment in childhood regarding adult height or future substance abuse have not been supported by existing studies.

Methylphenidate improves working memory and set-shifting in AD/HD: relationships to baseline memory capacity

OBJECTIVE

Catecholamine stimulant drugs are highly efficacious treatments for attention deficit/ hyperactivity disorders (AD/HD). Catecholamine modulation in humans influences performance of numerous cognitive tasks, including tests of attention and working memory (WM). Clear delineation of the effects of methylphenidate upon such cognitive functions in AD/HD would enhance understanding of the effects of drug treatment.

METHOD

Here we present a double-blind, placebo-controlled study of the cognitive effects of an acute dose of methylphenidate (c. .5 mg/kg) in 14 boys aged 10.86 (+/- 1.19) years meeting criteria for DSM-IV AD/HD. Current behaviour was ascertained using Conners' teacher and parent self-report questionnaires and IQ was tested using sub-tests from WISC-III-UK. Tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB) were selected to assess visuo-spatial recognition memory, spatial WM, planning, visual-search and attentional-set shifting.

RESULTS

Methylphenidate improved spatial WM, attentional-set shifting and visual-search task performance. Correlational analyses suggested possible relationships between WM capacity and spatial WM performance improvement. Also, poor performance on the attentional-set shifting task on placebo was associated with increased errors on the spatial WM task on placebo.

CONCLUSIONS

Methylphenidate may selectively improve both underlying cognitive difficulties in tasks dependent on intact fronto-striatal structures, and clinical symptoms of AD/HD. Pre-treatment measures may have some predictive value in determining individual differences in drug response.

Les traitements médicaux de l’enfant hyperactif

Treatment of hyperactive child is multimodal, a combination of behaviour therapy and medication. Stimulant drugs are the most often prescribed medications. In France, we use methylphenidate (Ritaline); its efficacy was demonstrated with mild side effects. New formulations of methylphenidate with prolonged action, and non-psychostimulant treatment (atomoxetine) are available in some countries, but not yet in France.

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.

Response to methylphenidate in children with attention deficit hyperactivity disorder and manic symptoms in the multimodal treatment study of children with attention deficit hyperactivity disorder titration trial

OBJECTIVE

Recent reports raise concern that children with attention deficit hyperactivity disorder (ADHD) and some manic symptoms may worsen with stimulant treatment. This study examines the response to methylphenidate in such children.

METHODS

Data from children participating in the 1-month methylphenidate titration trial of the Multimodal Treatment Study of Children with ADHD were reanalyzed by dividing the sample into children with and without some manic symptoms. Two "mania proxies" were constructed using items from the Diagnostic Interview Schedule for Children (DISC) or the Child Behavior Checklist (CBCL). Treatment response and side effects are compared between participants with and without proxies.

RESULTS

Thirty-two (11%) and 29 (10%) participants fulfilled criteria for the CBCL mania proxy and DISC mania proxy, respectively. Presence or absence of either proxy did not predict a greater or lesser response or side effects.

CONCLUSION

Findings suggest that children with ADHD and manic symptoms respond robustly to methylphenidate during the first month of treatment and that these children are not more likely to have an adverse response to methylphenidate. Further research is needed to explore how such children will respond during long-term treatment. Clinicians should not a priori avoid stimulants in children with ADHD and some manic symptoms.

Attention deficit hyperactivity disorder, combined type: better executive function performance with longer-term psychostimulant medication

OBJECTIVE

Executive function deficits are evident in primary school-age children with attention deficit hyperactivity disorder, combined type (ADHD-CT) and are possibly improved by longer-term psychostimulant medication. In contrast, a substantial subgroup of children with ADHD-CT become symptomatic despite longer-term psychostimulant medication use. We investigated the hypothesis that better executive function performance is associated with the use of longer-term psychostimulant medication in primary school-age children with ADHD-CT who are again symptomatic of ADHD-CT, despite its use.

METHOD

A cross-sectional study of 40 primary school-age psychostimulant medication-naïve children with ADHD-CT, 26 with symptomatic ADHD-CT and treated with psychostimulant medication, and 26 control children without ADHD-CT was conducted. Nonverbal tasks of executive function were compared across the three groups.

RESULTS

The longer-term psychostimulant medication-treated group had a better executive function performance, despite being symptomatic for ADHD-CT, than the psychostimulant medication-naïve group.

CONCLUSION

Improved executive function may be a marker of psychostimulant medication effect in children with ADHD-CT treated in the longer term. This improvement may not correlate with that of the ADHD-CT symptoms. Longitudinal studies are required.

Deficits in attention, motor control, and perception: a brief review

The concept of DAMP (deficits in attention, motor control, and perception) has been in clinical use in Scandinavia for about 20 years. DAMP is diagnosed on the basis of concomitant attention deficit/hyperactivity disorder and developmental coordination disorder in children who do not have severe learning disability or cerebral palsy. In clinically severe form it affects about 1.5% of the general population of school age children; another few per cent are affected by more moderate variants. Boys are overrepresented; girls are currently probably underdiagnosed. There are many comorbid problems/overlapping conditions, including conduct disorder, depression/anxiety, and academic failure. There is a strong link with autism spectrum disorders in severe DAMP. Familial factors and pre- and perinatal risk factors account for much of the variance. Psychosocial risk factors appear to increase the risk of marked psychiatric abnormality in DAMP. Outcome in early adult age was psychosocially poor in one study in almost 60% of unmedicated cases. There are effective interventions available for many of the problems encountered in DAMP.

Learning disability

Learning disability is common, affecting 1-2.5% of the general population in the Western world, and encompasses many different conditions. It usually leads to major functional impairment and lifelong need for support and interventions, not the least important of which are medical and health-care services. Rapid progress is being made in the understanding of the cause and pathogenesis of many learning disability syndromes, and these advances are likely to improve targeted interventions in the next decade. Many countries have abolished a learning disability specialty for medical professionals, but there is a great need to revive this niche of medical knowledge. We know little about quality of life and effects on families of people with learning disability, and research is needed to address these issues.

Selegiline in the treatment of attention deficit hyperactivity disorder in children: a double blind and randomized trial

Attention deficit hyperactivity disorder (ADHD) is a common disorder of childhood that affects 3% to 6% of school-age children. Conventional stimulant medications are recognized by both specialists and parents as useful symptomatic treatment. Nevertheless, approximately 30% of ADHD children treated with them do not respond adequately or cannot tolerate the associated adverse effects. Such difficulties highlight the need for alternative safe and effective medications in the treatment of this disorder. Selegiline is a type B monoamine oxidase inhibitor (MAOI) that is metabolized to amphetamine and methamphetamine stimulant compounds that may be useful in the treatment of ADHD. The authors undertook this study to further evaluate, under double-blind and controlled conditions, the efficacy of selegiline for ADHD in children. A total of 28 children with ADHD as defined by DSM IV were randomized to selegiline or methylphenidate dosed on an age and weight-adjusted basis at selegiline 5 mg/day (under 5 years) and 10 mg/day (over 5 years) (Group 1) and methylphenidate 1 mg/kg/day (Group 2) for a 4-week double-blind clinical trial. The principal measure of the outcome was the Teacher and Parent ADHD Rating Scale. Patients were assessed by a child psychiatrist at baseline, 14 and 28 days after the medication started. No significant differences were observed between the two protocols on the Parent and Teacher Rating Scale scores. Although the number of dropouts in the methylphenidate group was higher than in the selegiline group, there was no significant difference between the two protocols in terms of the dropouts. Decreased appetite, difficulty falling asleep and headaches were observed more in the methylphenidate group. The results of this study must be considered preliminary, but they do suggest that selegiline may be beneficial in the treatment of ADHD. In addition, a tolerable side effect profile may be considered as one of the advantages of selegiline in the treatment of ADHD.

Review of safety assessment methods used in pediatric psychopharmacology

OBJECTIVE

Elicitation is an essential and critical step in ascertaining adverse events (AEs). This report reviews elicitation methods used in published clinical trials of psychopharmacological agents in children.

METHOD

Pediatric psychopharmacology reports were reviewed for safety methods in the Medline database. Studies were included if they were published 1980 or later, provided data on AEs, and described the ascertainment methodology used for determining them.

RESULTS

A review of 196 pediatric psychopharmacology articles depicting safety assessments in clinical studies over the past 22 years revealed that there was no common method used for eliciting or reporting AE data.

CONCLUSION

The current inconsistency in safety data ascertainment is a major limitation that likely impairs the ability to promptly and accurately identify drug-induced AEs. Research on how best to standardize safety methods should be considered a priority in pediatric psychopharmacology.

Longer term effects of stimulant treatments for Attention-Deficit/Hyperactivity Disorder

Of pharmacological options available for Attention-Deficit/Hyperactivity Disorder (ADHD), stimulant medications are the most studied, the most commonly used, the most effective, and the first-line choice for treatment. Evidence of the short-term efficacy of methylphenidate (MPH) and other stimulants as well as behavioral treatments in the management of symptoms of ADHD is abundant This paper reviews therapeutic trials with a duration or follow-up period of 12 months or more and evaluates the longer term outcomes of available treatments for ADHD. The trials were reported by Ialongo et al. (1993), Horn et al. (1991), Schachar, Tannock, Cunningham, and Corkum (1997), Gillberg et al. (1997), Hechtman and Abikoff (1995), and the National Institute of Mental Health (MTA Cooperative Group, 1999a, 1999b).

Methylphenidate and substance abuse: a review of pharmacology, animal, and clinical studies

This article reviews pharmacological, animal, and human evidence regarding the abuse liability of methylphenidate (MPH). Findings are not always consistent, but evidence converges to suggest that although intravenous methylphenidate has some abuse potential, there is very little potential for oral MPH abuse. Furthermore, the available data suggests that children with Attention-Deficit/Hyperactivity Disorder (ADHD) who are treated with MPH are at lower risk for substance use disorder later in life. More longitudinal, prospective studies are needed to assess the long term effects of MPH treatment in ADHD.

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.

Psychopharmacological treatment of child and adolescent psychiatric inpatients in Finland

OBJECTIVE

The objective of this study was to investigate the use of psychopharmacological treatment in child and adolescent psychiatric inpatient treatment in Finland.

METHODS

The study is a cross-sectional study conducted in January 2000. The psychiatrist responsible for the inpatient treatment was asked to fill in a questionnaire for every inpatient who occupied a child or adolescent psychiatric bed during the chosen study day (n = 504 patients). Information on psychopharmacological treatment was obtained for 475 patients.

RESULTS

Forty-three percent had scheduled medication and 28% had "as required" medication. Of those with scheduled medication, 56% had neuroleptics and 45% antidepressants. In multivariate analysis, older age (13-18 years), involuntary treatment, and psychotic disorder were independently associated with scheduled medication, neuroleptic treatment, and as required medication prescription. Neurolepic treatment was also associated with a very low general functioning level (Children's Global Assessment Scale < 41). A diagnosis of depression and older age were associated with antidepressant treatment. Almost all patients with antidepressant treatment were treated with selective serotonin reuptake inhibitors.

CONCLUSIONS

Compared with data from a similarly conducted study in 1988, there is an increase especially in the use of antidepressant medication in inpatient care. Considering the increasing use of psychopharmacotherapy during the last 10 years as shown in the present study, the lack of research-based data on the efficacy and safety supporting their clinical use is a major problem in the treatment of disabling childhood mental health problems.

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.

Executive function profile of children with attention deficit hyperactivity disorder

We explored the neuropsychological profile for executive functions of children with attention deficit hyperactivity disorder (ADHD) to assess whether problems associated with the two most cited relevant processes--inhibition and attentional problems--were the core of any executive function difficulty. A battery of executive function tests was administered to 31 children with a clinical diagnosis of ADHD and to 33 normal control participants, all aged between 7 and 12. The executive function battery encompassed a number of tasks, selected because each had multiple measures: a sustained attention reaction time task, a related vigilance task, an adaptation of the Hayling Sentence Completion Test, an adaptation of the Brixton Spatial Rule Attainment Test, a Letter Fluency task, a number Stroop task, and an "n-back" working memory task. The overall pattern of the results fit well with those obtained in previous studies as far as abnormalities of the ADHD group in the domain of inhibitory processes, attentional functions, and executive functions. The children with ADHD, although performing well on baseline tasks, performed more poorly than the controls on all the experimental tasks with one borderline exception: Letter Fluency, where the children with ADHD showed a very different pattern than most adult frontal lobe subgroups. However, there was no specific impairment on measures of inhibitory processes. In addition, strategy generation and use were severely affected in the ADHD group. Particular findings fitted well with disorders of a high-level effort system and of a monitoring system.

Review of the evidence base for treatment of childhood psychopathology: externalizing disorders

This article reviews controlled research on treatments for childhood externalizing behavior disorders. The review is organized around 2 subsets of such disorders: disruptive behavior disorders (i.e., conduct disorder, oppositional defiant disorder) and attention-deficit/hyperactivity disorder (ADHD). The review was based on a literature review of nonresidential treatments for youths ages 6-12. The pool of studies for this age group was limited, but results suggest positive outcomes for a variety of interventions (particularly parent training and community-based interventions for disruptive behavior disorders and medication for ADHD). The review also highlights the need for additional research examining effectiveness of treatments for this age range and strategies to enhance the implementation of effective practices.

Attention deficit hyperactivity disorder in children: moving forward with divergent perspectives

Current controversy about diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) reflects the divergence between developmental and non-developmental approaches. While there is growing evidence for biological vulnerabilities associated with ADHD, we believe that environmental factors, including early problems in parental attachment, are also important in determining the type and timing of deficit that a child develops, the risk to academic and social performance and eventual outcome. We warn against labelling children with ADHD simply because they fulfil the cross-sectional diagnostic symptom criteria of the Diagnostic and statistical manual of mental disorders - 4th edition (DSM-IV). We advocate an integrated biopsychosocial approach to diagnosis and management with a thorough developmental assessment to identify developmental factors, such as deficits in early attachment, contributing to the presentation.

Response inhibition, hyperactivity, and conduct problems among preschool children

Investigated the relation among response inhibition, hyperactivity, and conduct problems in a nonclinical sample of 115 preschool children, using 2 different types of go/no-go tasks well as a Stroop-like task. In line with the assumption that hyperactivity is related to disinhibition, the results showed that it was the measures of response inhibition, and not other performance measures, that were related to teacher ratings of hyperactivity. There was also a significant relation between response inhibition and conduct problems. Interestingly, the correlation between response inhibition and conduct problems was not significant when partialling out the effect of hyperactivity, whereas the correlation between inhibition and hyperactivity did remain significant when controlling for conduct problems. Although the association between inhibition, hyperactivity, and conduct problems appeared to be partly different for boys and girls, these differences were not statistically significant.

Attention-deficit hyperactivity disorder: critical appraisal of extended treatment studies

We undertook a systematic review of the literature on the long-term treatment of attention-deficit hyperactivity disorder (ADHD). We used systematic strategies to identify randomized treatment studies in which treatment was administered for 12 weeks or more. We included 14 studies involving 1379 subjects. Because of the limited number of high-quality studies and the heterogeneity of outcome measures, we did not perform meta-analysis. We rated 5 studies as adequate for methodological quality. Five studies followed children for more than 26 weeks. Pharmacologic interventions were studied more frequently than non-pharmacologic ones. Six studies permitted evaluation of the effects of combined drug and behavioural intervention. Twenty-five different outcomes were measured using 26 different tests. Stimulant medication appears to reduce ADHD (7 studies), dysfunctional social behaviour (6 studies), and internalizing symptoms (2 studies). Available studies provide little evidence for improved academic performance with stimulants (3 studies). Medications other than stimulants have not been studied extensively (3 studies). Only 1 study showed that combination therapy adds to the effects of medication. Rigorous treatment research among representative samples of ADHD individuals is needed.

Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults

This practice parameter describes treatment with stimulant medication. It uses an evidence-based medicine approach derived from a detailed literature review and expert consultation. Stimulant medications in clinical use include methylphenidate, dextroamphetamine, mixed-salts amphetamine, and pemoline. It carries FDA indications for treatment of attention-deficit/hyperactivity disorder and narcolepsy.

[Evaluated treatment approaches in child and adolescent psychiatry I]

OBJECTIVES

The principle of evidence-based medicine is to integrate data concerning the efficacy of interventions into clinical practice. This article assesses the level of evaluation of psychosocial, psychopharmacological and combined interventions for mental disorders in childhood and adolescence (autistic disorders, hyperkinetic disorders, conduct disorders, tic disorders, enuresis, and encopresis).

METHODS

Three different levels of evaluation were defined for both psychosocial and psychopharmacological interventions: A (> or = 2 randomized controlled studies), B (1 randomized controlled study), and C (open studies and case studies). The level of evaluation was judged on the basis of original papers found in a comprehensive literature search.

RESULTS

For most disorders presented in this article there are several A-level treatments. The efficacy of both psychosocial and psychopharmacological interventions that target specific problem behaviors or symptoms, respectively, has been repeatedly demonstrated with regard to autistic disorders. Many studies have evaluated treatment approaches for hyperkinetic disorders and conduct disorders. With regard to the treatment of tic disorders in children and adolescents, far more studies evaluated the efficacy of pharmacotherapy than of psychotherapy.

CONCLUSIONS

Further research should compare the efficacy of different treatment approaches, examine specific and differential treatment effects and investigate combined treatment approaches.

Long-term effects of stimulant medications on the brain: possible relevance to the treatment of attention deficit hyperactivity disorder

In spite of extensive data supporting the short-term efficacy and safety of stimulant medications in the treatment of children with attention deficit hyperactivity disorder (ADHD), only limited information is available on the long-term effects of these drugs. On one hand, it is unclear whether treatment of ADHD with amphetamine-like stimulant medications for extended periods of time during child development can carry negative consequences, as manifested by an increase in use of illicit drugs, higher incidence of mania, psychosis, or other manifestations of psychopathology. On the other hand, it is not known whether the beneficial effects of stimulants extend beyond acute symptomatic relief and affect important outcome variables, such as later psychopathology, educational achievement, antisocial behavior, and social or occupational status. Data from naturalistic follow-up of clinical samples are limited by lack of appropriate controls and self-selection biases that are difficult to determine and control. These studies have reached conflicting conclusions, although most of them found no lasting negative effects of chronic stimulant treatment. Studies in animals, mainly in rodents, indicate that repeated exposure to stimulants leads to behavioral sensitization to the psychomotor effects of these medications. Extrapolation of these data to therapeutic use in humans is difficult given interspecies differences and the relatively high doses and parenteral route of administration usually employed in animals. This report is based on the proceedings of a workshop organized by the National Institute of Mental Health in December 1999 to discuss possible research approaches to studying the long-term effects of stimulants in children with ADHD. Both clinical and basic neuroscience data are reviewed, and opportunities for future research are highlighted.

Moderators and mediators of long-term adherence to stimulant treatment in children with ADHD

OBJECTIVE

To identify moderators and mediators of long-term adherence to stimulant medication in children with attention-deficit hyperactivity disorder (ADHD).

METHOD

Seventy-one children with ADHD were prescribed methylphenidate, followed prospectively on an annual basis for 3 years, and evaluated for adherence to stimulant treatment. The study occurred in Toronto between 1993 and 1997. Adherents were those who took methylphenidate, or another psychostimulant, for 5 or more days per week throughout the follow-up period, except for "drug holidays." Children who adhered at consecutive evaluations were compared with those who did not. Severity of ADHD, presence of oppositional defiant disorder/conduct disorder, learning difficulties, anxiety, age, family dysfunction, and socioeconomic adversity at baseline were investigated as moderators of adherence. Response to treatment at school, measured at 12 months, was investigated as a mediator of adherence.

RESULTS

Fifty-two percent of children adhered to stimulant treatment for 3 years. Absence of teacher-rated oppositional defiant disorder, more teacher-rated ADHD symptoms, and younger age at baseline predicted adherence.

CONCLUSIONS

Adherence to stimulant medications is a significant factor in the long-term treatment of children with ADHD.

Effect of repeated methylphenidate administration on presynaptic dopamine and behaviour in young adult rats

Methylphenidate, a dopamine reuptake inhibitor, is the most common treatment for attention-deficit hyperactivity disorder and may be prescribed for years, despite little evidence of any long-term benefit, nor knowledge of potential chronic side-effects. Therefore, this study examined the acute and longer-term behavioural effects and assessed striatal dopamine function following subchronic methylphenidate administration to adolescent rats. Male hooded Lister rats received methylphenidate (4 mg/kg i.p. twice daily for 4 days) or saline (1 ml/kg) and the acute locomotor and stereotype behaviour was monitored on days 1 and 4, novel object exploration on day 2 and, following 12 days drug withdrawal, the long-term effect examined on social interaction on day 16. Ex-vivo K+ (20 mM)- and methylphenidate (0.1 mM)-induced [3H]dopamine release from striatal slices and striatal monoamine content were measured on day 18. Compared with saline, methylphenidate induced mild hyperactivity without stereotypy but did not alter novel object exploration and, following withdrawal, had no long-term effect on social interaction. In striatal slices from controls, both K+ and methylphenidate elevated [3H]dopamine release (p < 0.01) while only combined treatment elevated release in methylphenidate pretreated rats, although striatal monoamine content was unaltered compared with control rats. In summary, a repeated dose of methylphenidate that had acute behavioural effects produced no long-term alteration in social interaction but attenuated presynaptic striatal dopamine function.

Can parents accurately perceive hyperactivity in their child?

In all, 1872 children were recruited as part of a larger study concerning food additives and behaviours in preschool children. This figure represented 70% of the whole population of 3 1/4 -year-old children resident on the Isle of Wight, UK. Parents completed an assessment concerning their perceptions of their child's behaviour. The results of this assessment were compared with scores on two validated parental questionnaires, the Weiss Werry Peters (WWP) hyperactivity scale and the Emotionality, Activity and Sociability Temperament Questionnaire (EAS), which were used to assess hyperactivity. The accuracy of parents in perceiving hyperactivity in their children was found to be around 50% if the child was hyperactive, and 89% if the child was not hyperactive. The implications of these findings for services are discussed. Frequencies of potential risk groups for future Attention Deficit Hyperactivity Disorder (ADHD) and Conduct Disorder were also suggested.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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