Treatment of attention-deficit/hyperactivity disorder: overview of the evidence

Long-term treatment of ADHD with stimulants: a large observational study of real-life patients

OBJECTIVE

To evaluate 410 real-life patients treated with stimulants and assessed systematically over several years.

METHOD

Naturalistic observational study. A database was compiled on the basis of a review of the medical charts of patients attending a specialized ADHD clinic.

RESULTS

The diversity of ADHD patients was evident from the comorbidity, age at start, comedication, and treatment needs over time. Dosages corresponded to guidelines in most patients, but some needed higher dosages or got along on lower dosages for long periods. Age at start and comorbidity influenced dosage, and dosage was associated to differential outcome groups.

CONCLUSION

The study findings underscored the diversity of ADHD patients and that individual factors should be taken into account when tailoring individual treatment schedules. Findings further showed that stimulant dosages are dynamic over time and depend on individual factors, that individual factors influence outcome, and that patients with ADHD should be individually monitored and stimulant dosages adjusted continuously.

Atypical behaviors and comorbid externalizing symptoms equally predict children with attention-deficit/hyperactivity disorder's social functioning

The goal of the current study was to determine within a clinical sample what differentiates children with ADHD who experience social functioning difficulties from those who appear to have healthy social functioning. Participants for this study included 62 children (mean age = 11.3 years) with a DSM-IV diagnosis of ADHD confirmed by a comprehensive clinical diagnostic assessment. Multiple indicators of children's social functioning were collected via parent report including: social skills, social adaptability, peer difficulties, and social quality of life. Parent reports of children's externalizing, internalizing, and atypical behaviors were also collected. Results indicated that both externalizing symptoms and atypical behaviors predicted children with ADHD's social functioning, even after controlling for ADHD symptoms severity. No association was found between internalizing symptoms and social functioning. The current study provides initial data suggesting that atypical behaviors found in children with ADHD are as powerful as comorbid externalizing symptoms in predicting social functioning difficulties. Due to the shared variance from relying solely on parent report, it will be critical for future research to replicate our findings using multi-informant data such as peer and teacher reports which provide unique information on children's social functioning.

Methylphenidate and μ opioid receptor interactions: a pharmacological target for prevention of stimulant abuse

Methylphenidate (MPH) is one of the most commonly used and highly effective treatments for attention deficit hyperactivity disorder (ADHD) in children and adults. As the therapeutic use of MPH has increased, so has its abuse and illicit street-use. Yet, the mechanisms associated with development of MPH-associated abuse and dependence are not well understood making it difficult to develop methods to help its mitigation. As a result, many ADHD patients especially children and youth, that could benefit from MPH treatment do not receive it and risk lifelong disabilities associated with untreated ADHD. Therefore, understanding the mechanisms associated with development of MPH addiction and designing methods to prevent it assume high public health significance. Using a mouse model we show that supra-therapeutic doses of MPH produce rewarding effects (surrogate measure for addiction in humans) in a conditioned place preference paradigm and upregulate μ opioid receptor (MOPR) activity in the striatum and nucleus accumbens, brain regions associated with reward circuitry. Co-administration of naltrexone, a non-selective opioid receptor antagonist, prevents MPH-induced MOPR activation and the rewarding effects. The MPH-induced MOPR activation and rewarding effect require activation of the dopamine D1 but not the D2-receptor. These findings identify the MOPR as a potential target for attenuating rewarding effects of MPH and suggest that a formulation that combines naltrexone with MPH could be a useful pharmaceutical approach to alleviate abuse potential of MPH and other stimulants.

Long-term outcomes with medications for attention-deficit hyperactivity disorder: current status of knowledge

Attention-deficit hyperactivity disorder (ADHD), a common neurobehavioural disorder characterized by inattention, hyperactivity and impulsivity, is a chronic disorder and often persists into adulthood. CNS stimulants have been the most well known treatment for ADHD for several decades due to their high effectiveness, good safety profiles and relatively minor adverse effects. Non-stimulant agents, including atomoxetine, extended-release guanfacine and extended-release clonidine (US FDA approved), and several non-FDA-approved agents, such as bupropion and tricyclic antidepressants (TCAs), were recently proven to be effective alternatives to the stimulants in several open-label and placebo-controlled trials. However, most medication trials for ADHD have been short term and thus have not provided information on the long-term outcomes of ADHD treatment. Since the medical treatment of many children with ADHD, especially those with more severe symptoms or co-morbid disorders, has to be continued for several years, recent studies have shifted their focus from the acute effectiveness of stimulants or non-stimulant drugs to the long-term outcomes of medications for ADHD. Evidence has shown that stimulants, along with the non-stimulants atomoxetine and extended-release guanfacine, are continuously effective for 24-month treatment periods with few and tolerable adverse effects.

Heterogeneity in the pharmacological treatment of children with ADHD: cognitive, behavioral, and social functioning differences

OBJECTIVE

To investigate the extent to which children with ADHD in various medication statuses (i.e., medication naïve, pure stimulant, stimulant plus another medication, nonstimulants) varied on cognitive or academic, behavioral, and social functioning during a psychoeducational assessment battery.

METHOD

Participants for this study consisted of 66 children (20 girls) with a Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV) diagnosis of ADHD confirmed by a comprehensive clinical diagnostic assessment, including the use of a semistructured interview and Conners' Parent Rating Scales. Standardized cognitive and academic measures along with parent report of medication status, behavioral, and social functioning were collected.

RESULTS

No differences were found among children in the various medication groups in terms of ADHD symptoms severity, academic performance, processing speed, verbal abilities, or perceptual reasoning skills. However, children in the medication-naïve group performed significantly better than the stimulant-plus-another-medication and nonstimulant groups in terms of overall cognitive abilities, working-memory skills, and social adaptability but had similar scores to children in the pure-stimulant group. Children in the pure-stimulant group also had marginally higher working-memory scores compared to children in the nonstimulant group but not compared to the stimulant-plus-another-medication group. The pure-stimulant group also had significantly lower externalizing and internalizing problems and higher social adaptability compared to the stimulant-plus-another-medication group but not compared to the medication-naïve or nonstimulant groups.

CONCLUSION

Findings showed evidence for distinct cognitive, behavioral, and social profiles among children with ADHD who are proactively not on medication, as well as differences among children with ADHD who are on only one stimulant versus a nonstimulant or stimulant-plus-another-medication regimen.

Differential effects of predictors on methylphenidate initiation and discontinuation among young people with newly diagnosed attention-deficit/hyperactivity disorder

OBJECTIVE

Previous population-based studies have identified factors accounting for differential utilization of psychotropic medications among young patients with attention-deficit/hyperactivity disorders (ADHDs); yet, few analyses have addressed changes in such factors that can occur in the help-seeking process. The aim of this study was to examine patient- and service provider-level predictors for methylphenidate (MPH) initiation and discontinuation.

METHOD

This cohort study included 10,153 newly diagnosed ADHD patients under 18 years of age in 2000, identified from the National Health Insurance Research Database. The risk association was estimated by time-dependent survival analyses, as indexed by hazard ratio.

RESULTS

Approximately 30% of young people received MPH treatment within the year of their ADHD diagnosis, and virtually none remained in treatment beyond 12 months. Regardless of co-morbidity status, the following were significantly associated with earlier initiation of MPH treatment: older age (e.g., adjusted hazard ratio [aHR] for age 12-17 = 4.5-7.6), lower socioeconomic status (aHR = 1.2-1.4), southern residence (aHR = 1.4-1.6), receiving the diagnosis while school was in session (aHR = 1.3-1.4), receiving the diagnosis from a physician specializing in pediatrics or psychiatry (aHR = 7.3-16.8), and receiving the diagnosis in a district hospital/clinic (aHR = 1.3-1.7). However, once treatment started, older ages appeared to increase the risk of early discontinuation by 15%, and the corresponding estimates for receiving initial MPH in a regional hospital or district hospital/clinic were 27% and 32%, respectively. Change in treatment location upon subsequent visit was associated with a 58% reduction in early discontinuation.

CONCLUSIONS

This information about time-varying predictors for MPH utilization throughout treatment may provide insight into the delivery of pediatric mental health services and has important implications for the design of clinical treatment programs.

Adrenergic α2A receptor gene is not associated with methylphenidate response in adults with ADHD

Adrenergic α2A receptor gene (ADRA2A) is one of the most promising candidate genes for ADHD pharmacogenetics. Thus far, three studies have investigated the association between the ADRA2A -1291 C>G polymorphism and the therapeutic response to methylphenidate (MPH) in children with ADHD, all of them with positive results. The aim of this study is to investigate, for the first time, the association between three ADRA2A polymorphisms (-1291 C>G, -262 G>A, and 1780 C>T) and the response to MPH in adults with ADHD. The sample comprises 165 Brazilians of European descent evaluated in the adult ADHD outpatient clinic of the Hospital de Clínicas de Porto Alegre. The diagnostic procedures followed the DSM-IV criteria. Drug response was assessed by both categorical and dimensional approaches, through the scales Swanson, Nolan, and Pelham Rating scale version IV and the Clinical Global Impression-Severity Scale, applied at the beginning and after the 30th day of treatment. We found no evidence of association between the three ADRA2A polymorphisms and the therapeutic response to MPH treatment. Our findings do not support a significant role for the ADRA2A gene in ADHD pharmacogenetics, at least among adult patients.

Serotonin (5-HT) precursor loading with 5-hydroxy-l-tryptophan (5-HTP) reduces locomotor activation produced by (+)-amphetamine in the rat

BACKGROUND

Evidence suggests that increases in synaptic serotonin (5-HT) can reduce the stimulant properties of amphetamine-type drugs. Here we tested the hypothesis that administration of the 5-HT precursor 5-hydroxy-l-tryptophan (5-HTP), along with the peripheral decarboxylase inhibitor benserazide, would decrease locomotor effects of (+)-amphetamine.

METHODS

Drug treatments were administered to conscious male rats undergoing in vivo microdialysis in nucleus accumbens. During dialysis sampling, rats were housed in chambers equipped with photobeams to detect forward locomotion (i.e., ambulation) and repetitive movements (i.e., stereotypy). Extracellular concentrations of dopamine (DA) and 5-HT were measured by high-pressure liquid chromatography with electrochemical detection.

RESULTS

5-HTP (10 & 30 mg/kg, i.p.) plus benserazide (30 mg/kg, i.p.) caused dose-related increases in 5-HT but failed to alter other parameters. (+)-Amphetamine (0.3 & 1.0 mg/kg, i.p.) produced dose-related increases in DA, ambulation and stereotypy. Combined administration of 5-HTP and (+)-amphetamine evoked large elevations in extracellular DA and 5-HT, but caused significantly less ambulation than (+)-amphetamine alone (~50% reduction).

CONCLUSIONS

Our results confirm that 5-HTP can decrease hyperactivity produced by (+)-amphetamine, even in the presence of elevations in dialysate DA. The data suggest that 5-HTP and (+)-amphetamine may be useful to broadly enhance monoamine function in the clinical setting, while reducing undesirable effects of (+)-amphetamine.

School accountability laws and the consumption of psychostimulants

Over the past decade, several states introduced varying degrees of accountability systems for schools, which became federal law with the passage of the No Child Left Behind Act of 2001. The intent of these accountability laws was to improve academic performance and to make school quality more observable. Nonetheless, schools have reacted to these pressures in several different ways, some of which were not intended. We make use of the variation across states and over time in specific provisions of these accountability laws and find that accountability pressures effect medical diagnoses and subsequent treatment options of school aged children. Specifically, children in states with more stringent accountability laws are more likely to be diagnosed with Attention Deficit/Hyperactivity Disorder (ADHD) and consequently prescribed psychostimulant drugs for controlling the symptoms. However, conditional on diagnosis, accountability laws do not further change the probability of receiving medication therapy.

Effect of methylphenidate on intelligence quotient scores in Chinese children with attention-deficit/hyperactivity disorder

BACKGROUND

Stimulants are the most effective drugs for attention-deficit/hyperactivity disorder (ADHD) symptoms. The purpose of this study was to explore the intervention effect of methylphenidate, a commonly used stimulant, on cognitive performance in ADHD children and whether the effect is associated with age, sex, different subtypes of ADHD, and drug dosage.

METHODS

Children with ADHD were divided into the following subtypes: combined type, predominantly inattentive type, and hyperactive/impulsive type. The intervention group consisted of 159 children treated with methylphenidate, and the control group consisted of 78 untreated patients. All 237 subjects were given a Wechsler Intelligence Scale for Children--Revised test at baseline, and 6 months later, they were retested. The scores of Verbal Intelligence Quotient (IQ) test, Performance IQ (PIQ) test, Full Scale IQ (FSIQ) test, and subtests were compared before and after the intervention.

RESULTS

At baseline, scores were not statistically different between the 2 groups. After 6 months, PIQ and FSIQ scores of intervention group were higher than those of the control group (P < 0.05). Compared with baseline scores, the intervention group, but not the control group, showed significant increases in Verbal IQ (P < 0.05), PIQ (P < 0.01), and FSIQ (P < 0.01). In the intervention group, the 5 subtests scores of PIQ improved significantly (P < 0.01). In the control group, none of the scores from the subtests showed statistical differences. Furthermore, there was no statistical difference between the change of IQ scores and children's age, sex, different subtypes of ADHD, and drug dosage.

CONCLUSIONS

Methylphenidate can enhance cognitive performance in ADHD patients thus evaluating their IQ scores, although the effect size seems to be relatively small. The result should not be indicated as an increase in intelligence.

Health literacy and task environment influence parents' burden for data entry on child-specific health information: randomized controlled trial

BACKGROUND

Health care systems increasingly rely on patients' data entry efforts to organize and assist in care delivery through health information exchange.

OBJECTIVES

We sought to determine (1) the variation in burden imposed on parents by data entry efforts across paper-based and computer-based environments, and (2) the impact, if any, of parents' health literacy on the task burden.

METHODS

We completed a randomized controlled trial of parent-completed data entry tasks. Parents of children with attention deficit hyperactivity disorder (ADHD) were randomized based on the Test of Functional Health Literacy in Adults (TOFHLA) to either a paper-based or computer-based environment for entry of health information on their children. The primary outcome was the National Aeronautics and Space Administration Task Load Index (TLX) total weighted score.

RESULTS

We screened 271 parents: 194 (71.6%) were eligible, and 180 of these (92.8%) constituted the study cohort. We analyzed 90 participants from each arm. Parents who completed information tasks on paper reported a higher task burden than those who worked in the computer environment: mean (SD) TLX scores were 22.8 (20.6) for paper and 16.3 (16.1) for computer. Assignment to the paper environment conferred a significant risk of higher task burden (F(1,178) = 4.05, P = .046). Adequate literacy was associated with lower task burden (decrease in burden score of 1.15 SD, P = .003). After adjusting for relevant child and parent factors, parents' TOFHLA score (beta = -.02, P = .02) and task environment (beta = .31, P = .03) remained significantly associated with task burden.

CONCLUSIONS

A tailored computer-based environment provided an improved task experience for data entry compared to the same tasks completed on paper. Health literacy was inversely related to task burden.

Treatment outcomes with methylphenidate formulations among patients with ADHD: retrospective claims analysis of a managed care population

OBJECTIVE

Describe treatment patterns, resource use, and predictors of methylphenidate (MPH) switch among children (6-12 years), adolescents (13-17 years), and adults (≥ 18 years) with attention-deficit/hyperactivity disorder (ADHD).

METHODS

This retrospective U.S. managed care database study used medical, pharmacy, and enrollment data to examine treatment patterns among patients with ≥ 1 ADHD diagnosis code (ICD-9 314.00-314.9), MPH pharmacy claims during 01/01/2004-09/30/2006, and no ADHD pharmacy claims in prior 6 months. Patients were followed for 1 year for dosage change, switch (change to non-MPH treatment), augmentation, persistence (number days on index medication) and adherence (days supplied/days persistent). End points were assessed by age group and MPH formulation. Cox proportional hazards modeling was conducted to determine predictors of MPH switch.

RESULTS

Among 23,860 MPH users, 51.4% had a dosing change, 14% switched to a non-MPH agent, and 4% augmented MPH therapy. Among those prescribed long-acting (LA) MPH (N = 14,681), switching rates were 14% for children, 13% for adolescents, and 16% for adults. Augmentation rates for LA MPH were <5%. Overall, 53% of patients were adherent with mean persistence of 219 days. For the subgroup of patients prescribed LA MPH (n = 14,681), adherence ranged from 49% (adolescents) to 59% (children); persistence varied between 183 days (adults) to 256 days (children). During the 1-year follow-up, office/clinic visits were the major driver of health care resource use in MPH patients (mean 9.7 visits/patient). Patients with psychiatric comorbidity utilized significantly greater services. Predictors of MPH switch included psychiatric comorbidity (hazards ratio [HR] 1.37; 95% confidence interval [CI] = 1.26-1.48; p < 0.0001) and specialty prescribers (HR 1.19, 95% CI = 1.04-1.35; p = 0.011). Potential limitations of this study include use of claims data for definition of drug usage; inclusion of medications approved for use in ADHD; assessment of switching that may not have captured short-term augmentation; absence of economic, clinical and other variables from the claims dataset that may have influenced treatment selection, and outcomes. The 6-month baseline period to determine newly treated patients may not guarantee exclusion of all previously treated patients who restart therapy after an extended period.

CONCLUSIONS

Children exhibited the highest persistence of MPH users. ADHD patients on MPH therapy with a psychiatric comorbidity may require additional follow-up to help improve adherence and reduce health care resource use.

Executive function deficits in children with attention-deficit/hyperactivity disorder and improvement with lisdexamfetamine dimesylate in an open-label study

OBJECTIVE

To assess the effects of lisdexamfetamine dimesylate (LDX) on executive function (EF) behaviors in children with attention-deficit/hyperactivity disorder (ADHD).

METHODS

This observational, open-label, 7-week, dose-optimization study of LDX (20-70  mg/day) in children with ADHD evaluated efficacy with the ADHD Rating Scale IV; safety measures included adverse events (AEs). EF was assessed with the Behavior Rating Inventory of Executive Function (BRIEF). Post hoc analyses examined BRIEF scores by sex, ADHD subtype, comorbid psychiatric symptoms, and common treatment-emergent AEs (TEAEs). ADHD Rating Scale IV scores were assessed in subjects categorized by baseline BRIEF global executive composite T scores with clinically significant (≥65) or not clinically significant (<65) impairment in EF.

RESULTS

Mean (standard deviation) change from baseline to endpoint for BRIEF of -17.9 (12.5) for Global Executive Composite, -15.4 (12.6) for Behavioral Regulation Index, and -17.6 (12.3) for Metacognition Index demonstrated improvement with LDX (pooled doses; p < 0.0001 for all). Improvements in BRIEF scores were seen regardless of sex, ADHD subtype, comorbid psychiatric symptoms, common TEAEs, or baseline EF impairment category. TEAEs included decreased appetite, decreased weight, irritability, insomnia, headache, upper abdominal pain, and initial insomnia.

CONCLUSIONS

Improvements were demonstrated in EF behaviors and ADHD symptoms with LDX. LDX safety profile was consistent with long-acting stimulant use.

Treatment stabilization in children and adolescents with attention-deficit/hyperactivity disorder: data from the Netherlands

OBJECTIVE

To evaluate the number of patients reaching stable treatment with a stimulant (methylphenidate or dexamphetamine) or non-stimulant (atomoxetine) attention-deficit/hyperactivity disorder (ADHD) medication approved for use in the Netherlands, and the time to treatment stabilization among children and adolescents aged 6-17 years.

RESEARCH DESIGN AND METHODS

Prescription data from the PHARMO medical record linkage system from 48 geo-demographic areas in the Netherlands (2003-2006) were analyzed from newly treated patients with ADHD aged 6-17 years. Only patients with ≥ 5 dispensings for any ADHD drug during follow-up (at least 12 months) and no missing information on type of drug, strength, and number of pills per day were included.

MAIN OUTCOME MEASURES

Attainment of a stable dosing regimen was defined as no change in type of drug (including a switch from an immediate release (IR) to a long-acting (LA) formulation), strength, and number of pills per day for five consecutive dispensings. Time to stable dosing regimen was defined as the number of days between the first dispensing for an ADHD drug and the first of five unchanged dispensings.

RESULTS

Of 4909 children or adolescents initiating treatment, 3099 met selection criteria. More patients starting therapy with LA methylphenidate (82.4%) achieved treatment stabilization during follow-up than with IR methylphenidate (74.8%; p < 0.01) or atomoxetine (69.8%; p < 0.05). More patients initiated on LA methylphenidate patients (43.9%) achieved treatment stabilization without changing their index medication or dose compared to those initiated on IR methylphenidate (25.3%) or atomoxetine (8.1%; p < 0.0001 for both comparisons). Among patients achieving treatment stabilization, those initiating treatment with LA methylphenidate had a significantly shorter time to treatment stabilization (14 days) than patients initially treated with IR methylphenidate (56 days; p < 0.001) or atomoxetine (31 days; p < 0.05). Mean number of pills per day varied between 1.0 and 1.8 at initial treatment and 1.1 and 1.9 at treatment stabilization. Potential limitations of the study include the use of ADHD-medication dispensing as a proxy for an ADHD diagnosis and the impact of different titration schedules for the various ADHD medications.

CONCLUSION

Overall, 2316 of the 3066 eligible patients (75.5%) achieved treatment stabilization during follow-up. Among children and adolescents with ADHD in the Netherlands, the time to treatment stabilization varied according to choice of initial treatment and was shortest for LA methylphenidate.

Attention deficit/hyperactivity disorder in primary school children of Tabriz, North-West Iran

This study aimed to estimate the prevalence of attention deficit/hyperactivity disorder (ADHD), as well as its subtypes, in elementary school children and their demographic characteristics. A random clustered sample of elementary students was selected from schools of Tabriz, North-West Iran. The clinical diagnosis of ADHD was based on DSM-IV-TR criteria using an interview with children who were selected as scoring high on the Conner's teacher rating scale. A total of 30 schools and 1658 students were evaluated. The prevalence rate of clinical ADHD in the elementary students of Tabriz was 9.7%. Only two had been diagnosed previously. The mean age (standard deviation) was 9.39 (1.27) years. ADHD was more common among boys, students of the third level and children with an un-educated mother or father. It was not related to the type of school, age or birth order. Students with ADHD had lower school performance and orderliness reported by the school. Inattentiveness was more common among schoolgirls while the most common subtype was the combined one. Inattentive students had a significantly lower school performance. ADHD is common in elementary schools of this region and is correlated with poor performance. Greater awareness of parents and teachers concerning children at risk is necessary for an early diagnosis.

Stimulant-responsive and stimulant-refractory aggressive behavior among children with ADHD

OBJECTIVES

The objective of this study was to examine factors that are associated with aggression that is responsive versus refractory to individualized optimization of stimulant monotherapy among children with attention-deficit/hyperactivity disorder (ADHD).

METHODS

Children who were aged 6 to 13 years and had ADHD, either oppositional defiant disorder or conduct disorder, significant aggressive behavior, and a history of insufficient response to stimulants completed an open stimulant monotherapy optimization protocol. Stimulant titration with weekly assessments of behavior and tolerability identified an optimal regimen for each child. Families also received behavioral therapy. Parents completed the Retrospective-Modified Overt Aggression Scale (R-MOAS) at each visit. Children were classified as having stimulant-refractory aggression on the basis of R-MOAS ratings and clinician judgment. Differences that pertained to treatment, demographic, and psychopathology between groups with stimulant monotherapy-responsive and -refractory aggression were evaluated.

RESULTS

Aggression among 32 (49.3%) of 65 children was reduced sufficiently after stimulant dosage adjustment and behavioral therapy to preclude adjunctive medication. Those who responded to stimulant monotherapy were more likely to benefit from the protocol's methylphenidate preparation (once-daily, triphasic release), showed a trend for lower average dosages, and received fewer behavioral therapy sessions than did children with stimulant-refractory aggression. Boys, especially those with higher ratings of baseline aggression and of depressive and manic symptoms, more often exhibited stimulant-refractory aggression.

CONCLUSIONS

Among children whose aggressive behavior develops in the context of ADHD and of oppositional defiant disorder or conduct disorder, and who had insufficient response to previous stimulant treatment in routine clinical care, systematic, well-monitored titration of stimulant monotherapy often culminates in reduced aggression that averts the need for additional agents.

Long-term efficacy of methylphenidate in enhancing attention regulation, social skills, and academic abilities of childhood cancer survivors

PURPOSE

Methylphenidate (MPH) ameliorates attention problems experienced by some cancer survivors in the short term, but its long-term efficacy is unproven.

PATIENTS AND METHODS

This study investigates the long-term effectiveness of maintenance doses of MPH in survivors of childhood brain tumors (n = 35) and acute lymphoblastic leukemia (n = 33) participating in a 12-month MPH trial. Measures of attention (Conners' Continuous Performance Test [CPT], Conners' Rating Scales [CRS]), academic abilities (Wechsler Individual Achievement Test [WIAT]), social skills (Social Skills Rating System [SSRS]), and behavioral problems (Child Behavior Checklist [CBCL]) were administered at premedication baseline and at the end of the MPH trial while on medication. A cancer control group composed of patients who were not administered MPH (brain tumor = 31 and acute lymphoblastic leukemia = 23) was assessed on the same measures 12 [corrected] months apart.

RESULTS

For the MPH group, repeated measures analysis of variance revealed significant improvement in performance on a measure of sustained attention (CPT indices, P < .05); parent, teacher, and self-report ratings of attention (CRS indices, P < .05), and parent ratings of social skills or behavioral problems (SSRS and CBCL indices; P < .05). In contrast, the cancer control group only showed improvement on parent ratings of attention (Conners' Parent Rating Scale indices; P < .05) and social skills (SSRS and CBCL indices; P < .05). There was no significant improvement on the academic measure (WIAT) in either group.

CONCLUSION

Attention and behavioral benefits of MPH for childhood cancer survivors are maintained across settings over the course of a year. Although academic gains were not identified, MPH may offer benefits in academic areas not assessed.

Chiropractic care for paediatric and adolescent Attention-Deficit/Hyperactivity Disorder: A systematic review

BACKGROUND

Psychostimulants are first line of therapy for paediatric and adolescent AD/HD. The evidence suggests that up to 30% of those prescribed stimulant medications do not show clinically significant outcomes. In addition, many children and adolescents experience side-effects from these medications. As a result, parents are seeking alternate interventions for their children. Complementary and alternative medicine therapies for behavioural disorders such as AD/HD are increasing with as many as 68% of parents having sought help from alternative practitioners, including chiropractors.

OBJECTIVE

The review seeks to answer the question of whether chiropractic care can reduce symptoms of inattention, impulsivity and hyperactivity for paediatric and adolescent AD/HD.

METHODS

Electronic databases (Cochrane CENTRAL register of Controlled Trials, Cochrane Database of Systematic reviews, MEDLINE, PsycINFO, CINAHL, Scopus, ISI Web of Science, Index to Chiropractic Literature) were searched from inception until July 2009 for English language studies for chiropractic care and AD/HD. Inclusion and exclusion criteria were applied to select studies. All randomised controlled trials were evaluated using the Jadad score and a checklist developed from the CONSORT (Consolidated Standards of Reporting Trials) guidelines.

RESULTS

The search yielded 58 citations of which 22 were intervention studies. Of these, only three studies were identified for paediatric and adolescent AD/HD cohorts. The methodological quality was poor and none of the studies qualified using inclusion criteria.

CONCLUSIONS

To date there is insufficient evidence to evaluate the efficacy of chiropractic care for paediatric and adolescent AD/HD. The claim that chiropractic care improves paediatric and adolescent AD/HD, is only supported by low levels of scientific evidence. In the interest of paediatric and adolescent health, if chiropractic care for AD/HD is to continue, more rigorous scientific research needs to be undertaken to examine the efficacy and effectiveness of chiropractic treatment. Adequately-sized RCTs using clinically relevant outcomes and standardised measures to examine the effectiveness of chiropractic care verses no-treatment/placebo control or standard care (pharmacological and psychosocial care) are needed to determine whether chiropractic care is an effective alternative intervention for paediatric and adolescent AD/HD.

Chiropractic diagnosis and management of non-musculoskeletal conditions in children and adolescents

Background

A great deal has been published in the chiropractic literature regarding the response, or lack thereof, of various common pediatric conditions to chiropractic care. The majority of that literature is of low scientific value (that is, case reports or case series). The purpose of this review is to summarize the literature from the point of view of clinicians, rather than researchers, and to discuss some additional detail of the conditions themselves.

Methods

Databases searched were PubMed, Mantis, Index to Chiropractic Literature, and CINAHL. Keywords were chiropractic paired with colic, crying infant, nocturnal enuresis, asthma, otitis media and attention deficit hyperactivity disorder.

Results

Most of the published literature centers around case reports or series. The more scientifically rigorous studies show conflicting results for colic and the crying infant, and there is little data to suggest improvement of otitis media, asthma, nocturnal enuresis or attention deficit hyperactivity disorder.

Discussion

The efficacy of chiropractic care in the treatment of non-musculoskeletal disorders has yet to be definitely proven or disproven, with the burden of proof still resting upon the chiropractic profession.

The mixed amphetamine salt extended release (Adderall XR, Max-XR) as an adjunctive to SSRIS or SNRIS in the treatment of adult ADHD patients with comorbid partially responsive generalized anxiety: an open-label study

To examine the changes in partially responsive anxiety symptoms utilizing adjunctive treatment with the mixed amphetamine salt extended release (Adderall XR, MAX-XR) in the treatment of adult ADHD patients, with comorbid refractory anxiety. Consenting adult patients (n = 32) with confirmed diagnosis of generalized anxiety (GA) and comorbid (ADHD) participated in this open-label study. All patients had significant comorbid anxiety symptoms (HAM-A > 7) and failed to respond to 8-week trials of Serotonin Reuptake Inhibitors (SSRIs) or Norepinephrine Reuptake inhibitors (SNRIs). All patients were treated with the "Mixed Amphetamine salts Extended Release Adderall XR, (MAS-XR), as adjunctive to SSRIs or to SNRIs and were followed for at least 12 weeks. The primary effectiveness measure was the Clinical Global Impression severity subscale (CGI-S). Other scales included the Hamilton Anxiety Scale (HAM-A), the adult ADHD Self-Report Scale (ASRS-v1.1) symptom checklist, and Sheehan's disability scale. Baseline measures prior to the treatment with MAS-XR were compared to those at 4, 8, and at 12 weeks of treatment. Monitoring for pulse, blood pressure, and weight changes was carried out at baseline and at end point. All patients completed this open-label trial. There was significant and robust resolution of symptoms of all effectiveness measures, including the symptoms of anxiety, as shown by changes from baseline in HAM-A, ASRS-v1.1, and CGI at 8 weeks. Also there was significant reduction in the disability score at 12 weeks. Patients tolerated the treatment, and there were no significant cardiovascular changes at 12 weeks. There was decrease in mean weight at 12 weeks by 2.2 kg (P < .001). Mixed amphetamine salts MAS-XR can be used in adult patients with ADHD and comorbid anxiety symptoms. Larger controlled studies are needed to support the effectiveness of mixed amphetamine salts in patients with comorbid anxiety symptoms. Treatments need to include the targeting of the ADHD symptoms effectively in order to achieve better resolution of anxiety symptoms.

Pharmacological treatment patterns among patients with attention-deficit/hyperactivity disorder: retrospective claims-based analysis of a managed care population

OBJECTIVE

To develop a descriptive profile of attention-deficit/hyperactivity disorder (ADHD) pharmacological treatment patterns in terms of persistence, adherence, augmentation, switching, and dosing changes; and to assess differences in treatment patterns with regard to ADHD medication type, class, and duration of action.

METHODS

This retrospective claims database analysis used medical data, pharmacy data, and enrollment information to examine treatment patterns among patients with at least one claim with a diagnosis code for ADHD and a filled prescription for ADHD medication (index therapy) during the period 01 January 2004 through 30 September 2006. Treatment persistence and adherence (days supplied/days persistent) were calculated. Dose changes, medication switching, and augmentation were analyzed at three levels of comparison: class (stimulant vs nonstimulant [atomoxetine]), drug type (amphetamine vs methylphenidate), and duration of action (short, intermediate, long). Statistical comparisons were made using the chi-square test for proportions and Student's t-test or the F-test from one-way ANOVA for means.

RESULTS

Of 60,010 patients meeting eligibility criteria, 58.4% were younger than age 18. Most (78.4%) were prescribed a stimulant as their index therapy. Persistence and adherence were greater for patients on stimulants (vs the nonstimulant), for patients on amphetamines (vs methylphenidates), and for patients on long-acting medications (vs short- and intermediate-acting medications; all p < 0.0001). Index drug dose changes were least likely among individuals taking the nonstimulant (vs stimulants), methylphenidates (vs amphetamines), or intermediate-acting drugs (vs short- and long-acting drugs; all p < 0.0001), and medication switches were more frequent among those on nonstimulants, methylphenidates, or short-acting drugs (all p < 0.0001). Subjects taking long-acting medication were less likely to augment with a drug with a different duration of action than those taking intermediate- or short-acting medication (p < 0.0001). This claims-based study is limited by possible discrepancies between claims and patient behaviors (i.e., a claim for a prescription does not necessarily indicate that the medication was taken as prescribed).

CONCLUSIONS

Patients were more stable on treatment compared with their respective comparator groups if their index therapy was a stimulant, long-acting drug, or amphetamine.

Predicting methylphenidate response in long-term survivors of childhood cancer: a randomized, double-blind, placebo-controlled, crossover trial

OBJECTIVE

To investigate the methylphenidate (MPH) response rate among childhood survivors of acute lymphoblastic leukemia (ALL) and brain tumors (BTs) and to identify predictors of positive MPH response.

METHODS

Cancer survivors (N = 106; BT = 51 and ALL = 55) identified as having attention deficits and learning problems participated in a 3-week, double-blind, crossover trial consisting of placebo, low-dose MPH (0.3 mg/kg), and moderate-dose MPH (0.6 mg/kg). Weekly teacher and parent reports on the Conners' Rating Scales were gathered.

RESULTS

Following moderate MPH dose, 45.28% of the sample was classified as responders. Findings revealed that more problems endorsed prior to the medication trial on parent and teacher ratings were predictive of positive medication response (p < .05).

CONCLUSIONS

MPH significantly reduces attention problems in a subset of childhood cancer survivors. Parent and teacher ratings may assist in identifying children most likely to respond to MPH so prescribing may be optimally targeted.

Effectiveness, safety, and tolerability of lisdexamfetamine dimesylate in children with attention-deficit/hyperactivity disorder: an open-label, dose-optimization study

OBJECTIVE

The aim of this study was to assess the effectiveness and safety of lisdexamfetamine dimesylate (LDX) in children with attention-deficit/hyperactivity disorder (ADHD).

METHOD

This was a 7-week, open-label study evaluating 20, 30, 40, 50, 60, or 70 mg/day LDX in 318 children aged 6-12 years with ADHD. The ADHD Rating Scale IV (ADHD-RS-IV) was the primary efficacy assessment. Secondary measures included the Clinical Global Impressions-Improvement (CGI-I), Expression and Emotion Scale for Children (EESC), and Behavior Rating Inventory of Executive Function (BRIEF). Safety assessments included treatment-emergent adverse events (TEAEs), vital signs, and electrocardiograms.

RESULTS

At end point, mean (standard deviation [SD]) improvement from baseline in ADHD-RS-IV total score was 28.6 (10.9) (p < 0.0001). Most subjects (89.9%) were rated "improved" (i.e., CGI-I 1 or 2). Improvements from baseline were observed in the EESC total and subscale scores (p < or = 0.0002). LDX treatment resulted in significant improvement on the Global Executive Composite, Behavioral Regulation, and Metacognition indices of the BRIEF (p < 0.0001). TEAEs (incidences > or =10%) were decreased appetite, decreased weight, irritability, insomnia, headache, upper abdominal pain, and initial insomnia.

CONCLUSIONS

LDX was effective and generally well tolerated with a safety profile consistent with long-acting stimulant use. There was overall improvement in ADHD symptoms and executive function measures and no worsening of emotional expression measures.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00500071.

Preferences for treatment of Attention-Deficit/Hyperactivity Disorder (ADHD): a discrete choice experiment

Background

While there is an increasing emphasis on patient empowerment and shared decision-making, subjective values for attributes associated with their treatment still need to be measured and considered. This contribution seeks to define properties of an ideal drug treatment of individuals concerned with Attention-Deficit/Hyperactivity Disorder (ADHD). Because of the lack of information on patient needs in the decision-makers assessment of health services, the individuals' preferences often play a subordinate role at present. Discrete Choice Experiments offer strategies for eliciting subjective values and making them accessible for physicians and other health care professionals.

Methods

The evidence comes from a Discrete Choice Experiments (DCE) performed in 2007. After reviewing the literature about preferences of ADHS we conducted a qualitative study with four focus groups consisting of five to eleven ADHS-patients each. In order to achieve content validity, we aimed at collecting all relevant factors for an ideal ADHS treatment. In a subsequent quantitative study phase (n = 219), data was collected in an online or paper-pencil self-completed questionnaire. It included sociodemographic data, health status and patients' preferences of therapy characteristics using direct measurement (23 items on a five-point Likert-scale) as well as a Discrete-Choice-Experiment (DCE, six factors in a fold-over design).

Results

Those concerned were capable of clearly defining success criteria and expectations. In the direct assessment and the DCE, respondents attached special significance to the improvement of their social situation and emotional state (relative importance 40%). Another essential factor was the desire for drugs with a long-lasting effect over the day (relative importance 18%). Other criteria, such as flexibility and discretion, were less important to the respondents (6% and 9%, respectively).

Conclusion

Results point out that ADHD patients and their family members have clear ideas of their needs. This is especially important against the backdrop of present discussions in the healthcare sector on the relevance of patient reported outcomes (PROs) and shared decision-making. The combination of the methods used in this study offer promising strategies to elicit subjective values and making them accessible for health care professionals in a manner that drives health choices.

A linguistic analysis of in-office dialogue among psychiatrists, parents, and child and adolescent patients with ADHD

OBJECTIVE

The aim was to evaluate in-office discussions of ADHD and psychiatric comorbidities.

METHOD

Naturally occurring interactions among 11 psychiatrists, 32 patients and their parents were recorded, with a focus on "complicated" patients (i.e., having or suspected to have >or= 1 psychiatric comorbidities and/or learning disabilities in addition to ADHD). Participants were interviewed separately post visit. Transcripts were analyzed using validated sociolinguistic methodologies.

RESULTS

Some 62% of patients were male, with an average age of 12.5 years, and 79% had a family history of ADHD. Visits were psychiatrist-driven, focusing on medication management and school performance, leaving management of comorbidities largely unaddressed. Post visit, 78% of parents and psychiatrists disagreed on patients' "most concerning behavior." Parents most often reported concern about aggression and oppositionality. Psychiatrists and parents emphasized different aspects of patients' personality, using deficit- and strength-based models, respectively.

CONCLUSION

Psychiatrists and parents interpreted the relationship between ADHD and comorbidities differently. The significant incidence of misalignment regarding worrisome behaviors warrants further exploration.

Cardiovascular effects of longer-term, high-dose OROS methylphenidate in adolescents with attention deficit hyperactivity disorder

OBJECTIVE

To examine the effects of high doses of extended-release methylphenidate (OROS MPH) on cardiovascular variables in adolescents with attention deficit hyperactivity disorder (ADHD).

STUDY DESIGN

ECG indices plus systolic blood pressure (SBP), diastolic BP (DBP) and heart rate (HR) were assessed during an open-label study of OROS MPH in 114 adolescents with ADHD (doses up to 1.5 mg/kg/d). Cardiovascular parameters were assessed at 6 weeks and 6 months.

RESULTS

Small but statistically significant changes in DBP and HR were observed at 6 weeks, without further increases up to 6 months' follow-up. A small but statistically significant increase in SBP was observed over time. Twenty-nine percent of patients had isolated elevations in BP readings prior to study entry, and 14% had >3 consecutive visits at which elevated BP were observed during OROS MPH treatment. No clinically significant changes in ECG parameters were observed. No serious cardiovascular adverse events occurred.

CONCLUSIONS

Treatment with relatively high doses of OROS MPH was associated with small but statistically significant mean increases in BP and HR, primarily during the first 6 weeks of treatment, without clinically meaningful changes in ECG. These observations are consistent with previous reports using lower doses.

Second opinions improve ADHD prescribing in a medicaid-insured community population

OBJECTIVE

The appropriate use of psychotropic medications in youths is an important public health concern. In this article, we describe a review process developed to monitor the use of stimulants and atomoxetine for attention-deficit/hyperactivity syndrome (ADHD) in youths receiving fee-for-service Medicaid services.

METHOD

Washington State Medicaid developed threshold safety parameters for ADHD medications through a process involving the community. A second opinion was mandated when safety thresholds based on dose, combination therapies, or age was exceeded. Use and cost were compared 2 years before and after the program began.

RESULTS

From May 2006 to April 2008, 5.35% of ADHD prescriptions exceeded safety thresholds, resulting in 1,046 second-opinion reviews. Of those, 538 (51.4%) resulted in a prescription adjustment. Adjustments were made to primary care physician (52%), psychiatrist (50%), nurse practitioner (54%), and physician assistant-written (51%) prescriptions. When the preperiod and postperiod were compared, second opinions reduced ADHD medication at high doses (53%), in combinations (44%), and for patients 5 years of age and younger (23%). The review process resulted in a savings of $1.2 million, with 538 fewer patients exceeding safety thresholds. This was a 10:1 return over administrative costs; however, the overall Medicaid expenditures for ADHD medication still increased because of higher unit costs and the preferential use by clinicians of newer brands entering the market.

CONCLUSIONS

A statewide second-opinion process reduced outlier ADHD medication prescription practices and was cost-effective. Suggestions for process and quality improvements in prescribing to children diagnosed with ADHD are discussed.

Beyond polemics: science and ethics of ADHD

What is attention-deficit hyperactivity disorder (ADHD)? Why are so many children being diagnosed with ADHD and prescribed medication? Are stimulant drugs an effective and safe treatment strategy? This article explores the current state of scientific research into ADHD and the key social and ethical concerns that are emerging from the sharp rise in the number of diagnoses and the use of stimulant drug treatments in children. Collaborations among scientists, social scientists and ethicists are likely to be the most promising route to understanding what ADHD is and what stimulant drugs do.

Atomoxetine for the treatment of attention-deficit/hyperactivity disorder in children and adolescents: a review

OBJECTIVE

This review examines and summarizes the pharmacodynamic and pharmacokinetic properties, short- and longer-term efficacy, the moderating effect of comorbid disorders, as well as short- and long-term safety and tolerability of atomoxetine for the treatment of pediatric attention-deficit/hyperactivity disorder (ADHD).

METHODS

A systematic literature search was performed to review the extant literature on articles pertaining to the pharmacological treatment with atomoxetine in pediatric and/or adolescent ADHD.

RESULTS

There is an extensive literature on atomoxetine; over 4000 children have participated in clinical trials of atomoxetine, demonstrating its short- and longer-term efficacy. In addition, studies have examined the moderating effect of comorbid disorders on atomoxetine response, as well as atomoxetine's therapeutic potential for other psychiatric conditions. Short- and longer-term safety and tolerability continue to be reported.

CONCLUSIONS

Atomoxetine is indicated for both acute and maintenance/extended treatment of pediatric ADHD. Clinicians and families must be familiar with atomoxetine's evidence base, including its profile of clinical response and its possible effectiveness in the presence of comorbidity.

Review of pediatric attention deficit/hyperactivity disorder for the general psychiatrist

Attention deficit/hyperactivity disorder (ADHD) is a common and impairing psychiatric condition, affecting significant numbers of children and adolescents. General psychiatrists serve, both by choice and out of necessity, in the assessment and treatment of children and adolescents who have ADHD and in the education of patients and their families. For many clinicians, however, there are numerous unanswered questions regarding the diagnosis and therapeutic interventions for ADHD. This article provides general psychiatrists with a practical overview and update on the assessment, diagnosis, and treatment of pediatric ADHD. Background information, recent relevant research, current evidence-based practice guidelines, and tips for clinical practice are reviewed in this article. The information is presented in a question-answer format.

A randomised controlled trial of the Neuro Emotional Technique (NET) for childhood Attention Deficit Hyperactivity Disorder (ADHD): a protocol

BACKGROUND

An abundance of literature is dedicated to research for the treatment of Attention Deficit Hyperactivity Disorder (ADHD). Most, is in the area of pharmacological therapies with less emphasis in psychotherapy and psychosocial interventions and even less in the area of complementary and alternative medicine (CAM).The use of CAM has increased over the years, especially for developmental and behavioral disorders, such as ADHD. 60-65% of parents with children with ADHD have used CAM. Medical evidence supports a multidisciplinary approach (i.e. pharmacological and psychosocial) for the best clinical outcomes. The Neuro Emotional Technique (NET), a branch of Chiropractic, was designed to address the biopsychosocial aspects of acute and chronic conditions including non-musculoskeletal conditions. Anecdotally, it has been suggested that ADHD may be managed effectively by NET.

DESIGN/METHODS

A placebo controlled, double blind randomised clinical trial was designed to assess the effectiveness of NET on a cohort of children with medically diagnosed ADHD. Children aged 5-12 years who met the inclusion criteria were randomised to one of three groups. The control group continued on their existing medical regimen and the intervention and placebo groups had the addition of the NET and sham NET protocols added to their regimen respectively. These two groups attended a clinical facility twice a week for the first month and then once a month for six months. The Conners' Parent and Teacher Rating Scales (CRS) were used at the start of the study to establish baseline data and then in one month and in seven months time, at the conclusion of the study. The primary outcome measures chosen were the Conners' ADHD Index and Conners' Global Index. The secondary outcome measures chosen were the DSM-IV: Inattentive, the DSM-IV:Hyperactive-Impulsive, and the DSM-IV:Total subscales from the Conners' Rating Scales, monitoring changes in inattention, hyperactivity and impulsivity. Calculations for the sample size were set with a significance level of 0.05 and the power of 80%, yielding a sample size of 93.

DISCUSSION

The present study should provide information as to whether the addition of NET to an existing medical regimen can improve outcomes for children with ADHD.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registration Number: ANZCTRN 012606000332527.

Growth effects of methylphenidate among childhood cancer survivors: a 12-month case-matched open-label study

BACKGROUND

To investigate the effect of stimulant medication [methylphenidate (MPH)] on growth patterns among survivors of childhood cancer (acute lymphoblastic leukemia or brain tumor).

PROCEDURE

Using a case-matched comparison design, childhood cancer survivors participating in a 12-month open-label MPH trial (n = 51) were compared with childhood cancer survivors not taking MPH (n = 51). Measures of body mass index (BMI), height, and weight were obtained at hospital visits and corrected for gender and age using Centers for Disease Control normative data.

RESULTS

Significant deceleration of BMI and weight, but not height, was observed during the 12-month MPH trial for those children taking MPH.

CONCLUSIONS

Childhood cancer survivors taking MPH experience significant, though modest, deceleration of BMI and weight across the first year of MPH intervention. The absence of height deceleration, and the presence of only modest BMI and weight deceleration, suggests that MPH is reasonably well tolerated by childhood cancer survivors with respect to growth. Such findings are encouraging in light of increasing evidence that MPH mitigates some of the cognitive late-effects of cancer treatments. Nevertheless, on a case-by-case basis, clinicians should balance the intended benefits of MPH with potential growth effects in this vulnerable population.

Stimulant dosing for children with ADHD: a medical claims analysis

OBJECTIVE

To evaluate stimulant dosing patterns in the community treatment of children with attention-deficit/hyperactivity disorder (ADHD).

METHOD

Claims data from U.S. managed care organizations (2000-2004) were analyzed for patients ages 6 to 12 years treated for ADHD with osmotically released oral system (OROS) methylphenidate (MPH; n = 3,815), immediate-release (IR) MPH (n = 1,960), mixed amphetamine salts extended-release (MAS XR; n = 1,847), or IR MAS (n = 1,937), and who filled prescriptions covering at least 72 of the first 90 days of treatment.

RESULTS

The mean initial and maximum dosages were 23.8 and 33.4 mg/day for OROS MPH, 14.8 and 21.8 mg/day for IR MPH, 12.7 and 17.4 mg/day for MAS XR, and 11.2 and 16.5 mg/day for IR MAS. Dose titration occurred in 51.8% (MAS XR) to 61.6% (IR MPH) of patients. Lower initial dose and three or more visits for the treatment of ADHD during the first 90 days of treatment were associated with dose titration. Maximum dose was significantly related to higher initial dose and titration for all four stimulants. For children treated with OROS MPH or IR MAS, treatment by a psychiatrist was significantly related to higher maximum dose.

CONCLUSIONS

Among children with ADHD who continue stimulants through the first 3 months of treatment, dosing in the community treatment of ADHD tends to be lower than doses used in clinical trials. When titration does occur, it is linked to lower initial dosing, clinical monitoring, higher final stimulant doses, and treatment by a psychiatrist.

Versorgungsstudie zum Marburger Konzentrationstraining (MKT) bei Grundschulkindern mit Symptomen einer Aktivitäts- und Aufmerksamkeitsstörung

In der vorliegenden Versorgungsstudie wurden die Effekte des „Marburger Konzentrationstraining“ (MKT, Krowatschek, 2000 ) untersucht. 125 Grundschulkinder im Alter von 6 – 11 Jahren mit unterschiedlich stark ausgeprägten Symptomen einer Aktivitäts- und Aufmerksamkeitsstörung und ihre Eltern nahmen an dem in Kleingruppen durchgeführten kognitiv-behavioralen Training teil. Die ADHS-Symptome der Kinder wurden vor der Intervention, direkt danach und drei Monate nach Abschluss derselben erhoben. Im jeweiligen Vorher-Nachher-Vergleich ergab sich ein Rückgang der Symptomatik im Elternurteil direkt nach dem Training. Bei der Follow-up-Befragung zeigte sich eine weitere signifikante Verringerung der Unaufmerksamkeitssymptome. Zusätzlich wurde erhöhte Selbstständigkeit der Kinder in der Hausaufgabensituation sowohl während des Trainings als auch in den drei Monaten danach berichtet. Es zeigt sich hier also ein positiver Effekt einer relativ niederschwelligen und kurzzeitigen Intervention.

Methylphenidate potentiates morphine-induced antinociception, hyperthermia, and locomotor activity in young adult rats

The goal of this study was to determine if the exaggerated morphine-induced conditioned place preference (CPP) response seen in adult rats after preweanling methylphenidate exposure is unique to reward-mediated behaviors or is indicative of generalized changes in opioid-mediated behaviors. Rats were exposed to saline or methylphenidate (2.0 or 5.0 mg/kg) for 10 consecutive days starting on postnatal (PD) 11 with testing beginning on PD 60. In Experiment 1, morphine-induced (0, 2.5, 5.0 or 10.0 mg/kg) antinociception was assessed using the tail immersion and hot plate tasks. In Experiment 2, morphine-induced (0, 2.5, 5.0, or 10.0 mg/kg) hyperthermia and locomotor activity were measured. Morphine caused an increase in antinociception, with early methylphenidate (5.0 mg/kg) exposure potentiating the effects of 5.0 mg/kg morphine. Rectal temperatures were elevated after morphine, with the greatest increase occurring in male rats. Methylphenidate potentiated the hyperthermic effects of morphine (10.0 mg/kg) but only in males. Moderate doses (2.5 and 5.0 mg/kg) of morphine increased the locomotor activity of adult rats, while a higher dose (10.0 mg/kg) decreased locomotion. Interestingly, methylphenidate-pretreated females showed increased locomotor activity relative to controls. These results suggest that early methylphenidate exposure induces general changes in opioid system functioning that are not specific to reward-mediated behaviors.

Review of the literature regarding early intervention for children and adolescents aged 0-15 experiencing a first-episode psychiatric disturbance

AIM

The purpose of this review is to report on existing literature regarding children and adolescents younger than 16 years of age experiencing a first-episode psychiatric disturbance. Rather than providing a comprehensive list of service implications, this paper identifies some of the gaps in knowledge and practice to encourage ongoing analysis regarding better practices for early intervention for children and adolescents experiencing a first-episode psychiatric disturbance.

METHODS

A search was conducted to identify key evidence-based literature published from 1985 to 2007 discussing various aspects of child and youth mental health in Canada, the USA, the UK, Australia and New Zealand. The review also included 'grey' literature. Categories of information include diagnoses, pharmacological and non-pharmacological treatment, prevalence, environmental and other risk factors, and demographic variables.

RESULTS

Understanding first-episode psychiatric disturbance for patients under the age of 16 years is limited because of a scarcity of controlled studies focusing on this population. Programme evaluations are sparse, perhaps because of the small number of specialized units servicing this population. It may be helpful to enlist early intervention psychosis programmes that have been successful in assisting young people aged 16-24 in the development of better practices and care outcomes for younger age groups.

CONCLUSIONS

The authors highlight information that has the potential to assist in optimizing care for those youth younger than 16 years experiencing or exhibiting signs of a first-episode psychiatric disturbance.

Quantitative electroencephalography and attention-deficit/hyperactivity disorder: implications for clinical practice

Although behavioral symptoms of inattention, impulsivity, and hyperactivity serve as a foundation for the accurate diagnosis of attention-deficit/hyperactivity disorder (ADHD), the low interrater reliability and specificity of behavioral rating scales and the absence of comprehensive screening for medical conditions that mimic ADHD have created a barrier to the effective treatment of ADHD. Recently published studies using quantitative electroencephalographic techniques have identified abnormal patterns of cortical activation through power spectral analysis, in event-related cortical potentials, and in slow cortical potentials that may serve as a basis for overcoming these barriers. This paper reviews the initial evidence indicating that power spectral analysis and event-related cortical potentials may be useful in differentiating ADHD from other psychiatric disorders, helping in medication selection, evaluating medication response, and improving the rate of treatment initiation and maintenance. Studies examining electroencephalogram biofeedback (neurotherapy) are reviewed using published efficacy guidelines.