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

Switching from oral extended-release methylphenidate to the methylphenidate transdermal system: continued attention-deficit/hyperactivity disorder symptom control and tolerability after abrupt conversion

OBJECTIVE

To evaluate symptom control and tolerability after abrupt conversion from oral extended-release methylphenidate (ER-MPH) to methylphenidate transdermal system (MTS) via a dose-transition schedule in children with attention-deficit/hyperactivity disorder (ADHD).

METHODS

In a 4-week, prospective, multisite, open-label study, 171 children (164 intent-to-treat) with diagnosed ADHD aged 6-12 years abruptly switched from a stable dose of oral ER-MPH to MTS in nominal dosages of 10, 15, 20, and 30 mg using a predefined dose-transition schedule. After the first week on the scheduled dose, the dose was titrated to optimal effect. The primary effectiveness outcome was the change from baseline (while taking ER-MPH) to week 4 in ADHD-Rating Scale-IV (ADHD-RS-IV) total scores. Adverse events (AEs) were assessed throughout the study.

RESULTS

Most subjects (58%) remained on the initial MTS dose defined by the dose-transition schedule; 38% increased and 4% decreased their MTS dose for optimization. MTS dose optimization resulted in significantly better ADHD-RS-IV total (mean +/- SD) scores at week 4 than at baseline (9.9 +/- 7.47 vs. 14.1 +/- 7.48; p < 0.0001). The most commonly reported AEs included headache, decreased appetite, insomnia, and upper abdominal pain. Four subjects (2.3%) discontinued because of application site reactions and three discontinued because of other AEs.

CONCLUSIONS

Abrupt conversion from a stable dose of oral ER-MPH to MTS was accomplished using a predefined dose-transition schedule without loss of symptom control; however, careful titration to optimal dose is recommended. Most AEs were mild to moderate and, with the exception of application site reactions, were similar to AEs typically observed with oral MPH. Limitations of this study included its open-label sequential design without placebo, which could result in spurious attribution of improvement to the study treatment and precluded superiority determinations of MTS over baseline ER-MPH treatment. The apparent superiority of MTS was likely due to more careful titration and clinical monitoring rather than the product itself. ClinicalTrials.gov: NCT00151983.

Latent transition models with latent class predictors: attention deficit hyperactivity disorder subtypes and high school marijuana use

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder which is most often diagnosed in childhood with symptoms often persisting into adulthood. Elevated rates of substance use disorders have been evidenced among those with ADHD, but recent research focusing on the relationship between subtypes of ADHD and specific drugs is inconsistent. We propose a latent transition model (LTM) to guide our understanding of how drug use progresses, in particular marijuana use, while accounting for the measurement error that is often found in self-reported substance use data. We extend the LTM to include a latent class predictor to represent empirically derived ADHD subtypes that do not rely on meeting specific diagnostic criteria. We begin by fitting two separate latent class analysis (LCA) models by using second-order estimating equations: a longitudinal LCA model to define stages of marijuana use, and a cross-sectional LCA model to define ADHD subtypes. The LTM model parameters describing the probability of transitioning between the LCA-defined stages of marijuana use and the influence of the LCA-defined ADHD subtypes on these transition rates are then estimated by using a set of first-order estimating equations given the LCA parameter estimates. A robust estimate of the LTM parameter variance that accounts for the variation due to the estimation of the two sets of LCA parameters is proposed. Solving three sets of estimating equations enables us to determine the underlying latent class structures independently of the model for the transition rates and simplifying assumptions about the correlation structure at each stage reduces the computational complexity.

Kognitiv-behaviorale Strategien in der Behandlung von Erwachsenen mit ADHS

Neben der Psychopharmakotherapie mit Stimulanzien ist Psychotherapie ein wichtiger Teil der ADHS-Behandlung bei Erwachsenen. Folgende Zielbereiche werden psychotherapeutisch behandelt: Unaufmerksamkeit und Vergesslichkeit, Impulsivität, Hyperaktivität, Desorganisation, dysfunktionale Kognitionen, Gefühlsregulation, Stresstoleranz, Selbstwertgefühl, Kommunikation und Komorbiditäten. Im Beitrag soll ein Überblick zu den psychotherapeutischen Techniken gegeben werden, die in der Behandlung der ADHS bei Erwachsenen verwendet werden.

Parent-reported homework problems in the MTA study: evidence for sustained improvement with behavioral treatment

Parent-report of child homework problems was examined as a treatment outcome variable in the MTA-Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (ADHD). Five hundred seventy-nine children ages 7.0 to 9.9 were randomly assigned to either medication management, behavioral treatment, combination treatment, or routine community care. Results showed that only participants who received behavioral treatment (behavioral and combined treatment) demonstrated sustained improvements in homework problems in comparison to routine community care. The magnitude of the sustained effect at the 10-month follow-up assessment was small to moderate for combined and behavioral treatment over routine community care (d = .37, .40, respectively). Parent ratings of initial ADHD symptom severity was the only variable found to moderate these effects.

Does switching from oral extended-release methylphenidate to the methylphenidate transdermal system affect health-related quality-of-life and medication satisfaction for children with attention-deficit/hyperactivity disorder?

BACKGROUND

To evaluate health-related quality of life (HRQL) and medication satisfaction after switching from a stable dose of oral extended-release methylphenidate (ER-MPH) to methylphenidate transdermal system (MTS) via a dose-transition schedule in children with attention-deficit/hyperactivity disorder (ADHD).

METHODS

In a 4-week, multisite, open-label study, 171 children (164 in the intent-to-treat [ITT] population) aged 6-12 years diagnosed with ADHD abruptly switched from a stable dose of oral ER-MPH to MTS nominal dosages of 10, 15, 20, and 30 mg using a predefined dose-transition schedule. Subjects remained on the scheduled dose for the first week, after which the dose was then titrated to an optimal effect. The ADHD Impact Module-Children (AIM-C), a disease-specific validated HRQL survey instrument measuring child and family impact, was used to assess the impact of ADHD symptoms on the lives of children and their families at baseline and study endpoint. Satisfaction with MTS use was assessed via a Medication Satisfaction Survey (MSS) at study endpoint. Both the AIM-C and MSS were completed by a caregiver (parent/legally authorized representative). Tolerability was monitored by spontaneous adverse event (AE) reporting.

RESULTS

AIM-C child and family HRQL mean scores were above the median possible score at baseline and were further improved at endpoint across all MTS doses. Similar improvements were noted for behavior, missed doses, worry, and economic impact AIM-C item scores. Overall, 93.8% of caregivers indicated a high level of satisfaction with their child's use of the study medication. The majority of treatment-emergent AEs (> 98%) were mild to moderate in intensity, and the most commonly reported AEs included headache, decreased appetite, insomnia, and abdominal pain. Seven subjects discontinued the study due to intolerable AEs (n = 3) and application site reactions (n = 4).

CONCLUSION

This study demonstrates that MTS, when carefully titrated to optimal dose, may further improve child and family HRQL, as well as behavioral, medication worry, and economic impact item scores, as measured by the AIM-C in subjects switching to MTS from a stable dose of routinely prescribed oral ER-MPH after a short treatment period. Furthermore, following the abrupt conversion from oral ER-MPH to MTS, the majority of caregivers reported being highly satisfied with MTS as a treatment option for their children with ADHD.

TRIAL REGISTRATION

NCT00151983.

Sintomas e sinais de respiração predominantemente oral em adolescentes com transtorno de déficit de atenção/hiperatividade e queixa de prejuízo escolar

OBJETIVOS: caracterizar sintomas e sinais da Respiração Predominantemente Oral em adolescentes com Transtorno de Déficit de Atenção/Hiperatividade e queixa de prejuízo escolar e relacionar as características com os Tipos do Transtorno de Déficit de Atenção/Hiperatividade, gênero e faixa etária. MÉTODOS: realizada no ADOLESCENTRO, instituição pública do Distrito Federal, com 115 adolescentes de ambos os gêneros, faixa etária 10-18 anos, apresentando queixa de prejuízo escolar e Transtorno do Déficit de Atenção/Hiperatividade. Histórico dos sintomas diurnos e noturnos dos dois aos doze anos foi analisado e sinais da Respiração Predominantemente Oral. RESULTADOS: alta ocorrência (86,95%) de sintomas e sinais da Respiração Predominantemente Oral. Registrou-se associação entre amigdalite e tipos do Transtorno de Déficit de Atenção/Hiperatividade com maior frequência no Tipo II hiperativo (60%), sialorreia no travesseiro com gênero predominando o masculino (65,5%) e respiração oral diurna (64,7%), respiração oral noturna (82,4%) e sialorreia no travesseiro (64,7%) todas estas com a faixa etária de 10 a 12 anos. Houve associação entre lábios (54,3%) e língua (54,3%) não funcionais e faixa etária de 10 a 12 anos. Encontrou-se diferença estatisticamente significante para expulsões (20%), suspensões (70%), advertências (100%) e tipos de Transtorno de Déficit de Atenção/Hiperatividade com maior freqüência no Tipo II hiperativo. CONCLUSÃO: avaliação da respiração em pacientes com Transtorno do Déficit de Atenção/Hiperatividade e queixa de prejuízo escolar é fundamental, pois dificuldades escolares podem estar associadas à história pregressa de respiração oral e Distúrbios Respiratórios do Sono comuns nestes quadros.

Inattention, hyperactivity, oppositional-defiant symptoms and school failure

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) is associated with school failure. Inattention has been mainly implicated for this association. Oppositional-defiant disorder's (ODD) impact on academic performance remains controversial, because of the high comorbidity between ODD and ADHD.

OBJECTIVE

To understand the role of inattention (IN), hyperactivity (H/I) and ODD in school failure.

METHOD

Parents and teachers filled out SNAP-IV questionnaires for 241 / 6th grade students. The associations of the scores of oppositional-defiant (OP), H/I and IN symptoms with school year failure were calculated.

RESULTS

IN was strongly correlated with school failure. H/I and OP were not associated with school failure, when controlled for IN.

CONCLUSION

OP and H/I symptoms do not play an important role in school failure, when controlled for IN symptoms. Our study supports the cross-cultural role of IN as a major predictor of school failure.

An 8-year follow-up study of profiles and predictors of methylphenidate use in a nationwide sample of boys

OBJECTIVES

To identify methylphenidate profiles over several years in a national sample of boys and examine behavioral and sociodemographic predictors of use.

STUDY DESIGN

Five cycles of a Canadian survey were used, resulting in 1447 boys followed from 2 to 3 years to 10 to 11 years. Mother reports of boys' methylphenidate use from 4 to 5 years to 10 to 11 years were used to identify profiles over time. Mother-reported sociodemographic and child behavior data at 2 to 3 years were then used to predict methylphenidate profiles.

RESULTS

Three methylphenidate profiles were identified: no use (87.2%); slow-rising, intermittent (11.2%); and fast-rising, stable (1.6%). Sociodemographic variables were not significant predictors. Boys with greater hyperactivity-impulsivity, greater inattention, and less disruptive behavior were more likely to belong to the fast-rising, stable methylphenidate profile. Although 13% of boys were using methylphenidate over time, there were 2 heterogeneous profiles. In the first profile, there were very few initial users followed by a steady increase in the number of boys using methylphenidate over time. Among these boys, however, use was inconsistent over time. In the second profile, there was a sharp onset of methylphenidate use on school entry, followed by consistent use thereafter.

CONCLUSIONS

These findings have implications for the treatment effectiveness of attention deficit-hyperactivity disorder symptoms. It is important to continue examining the role of disruptive behavior because its co-occurrence with attention deficit-hyperactivity disorder symptoms and methylphenidate use is complex.

Self-reported ADHD and adjustment in college: cross-sectional and longitudinal findings

OBJECTIVE

To examine the association between self-reported ADHD and college adjustment.

PARTICIPANTS

Study 1 included nearly 3400 undergraduates attending a public and private university. Study 2 included 846 students who participated during freshman and sophomore year.

METHOD

Students completed a web-based survey that assessed diagnostic status and adjustment in multiple domains.

RESULTS

Relative to other students, those with self-reported ADHD had lower GPAs and reported more academic concerns, depressive symptoms, social concerns, emotional instability, and substance use. Overall, however, most were making satisfactory adjustments in these domains. Benefits of medication treatment were not found. Freshman year ADHD predicted lower GPA, increased academic concerns and alcohol use, and smoking initiation.

CONCLUSION

Students with ADHD struggled relative to peers but most were adjusting reasonably well across multiple domains. Future research should move beyond the use of self-reported diagnosis and more carefully examine the impact of medication treatment in this population.

Childhood and adolescent hyperactivity-inattention symptoms and academic achievement 8 years later: the GAZEL Youth study

BACKGROUND

Children with attention deficit/hyperactivity disorder (ADHD) are at risk of negative academic outcomes. However, relatively few studies in this area have been based on long-term longitudinal designs and community-based settings. This study examined the link between childhood hyperactivity-inattention symptoms (HI-s) and subsequent academic achievement in a community setting, controlling for other behavioural symptoms, socio-economic status (SES) and environmental factors at baseline.

METHOD

The sample consisted of 1264 subjects (aged 12 to 26 years at follow-up) recruited from the longitudinal GAZEL Youth study. Psychopathology, environmental variables and academic outcomes were measured through self-reports. Multivariate modelling was performed to evaluate the effects of childhood HI-s and other risk factors on academic achievement 8 years later.

RESULTS

HI-s independently predicted grade retention [adjusted odds ratio (OR) 3.58, 95% confidence interval (CI) 2.38-5.39], failure to graduate from secondary school (adjusted OR 2.41, 95% CI 1.43-4.05), obtaining a lower-level diploma (adjusted OR 3.00, 95% CI 1.84-4.89), and lower academic performance. These results remained significant even after accounting for school difficulties at baseline. Negative academic outcomes were also significantly associated with childhood symptoms of conduct disorder (CD), even after accounting for adjustment variables.

CONCLUSIONS

This longitudinal survey replicates, in a general population-based setting, the finding of a link between HI-s and negative academic outcomes.

Long-term safety and effectiveness of lisdexamfetamine dimesylate in adults with attention-deficit/ hyperactivity disorder

OBJECTIVE

To evaluate the long-term safety and effectiveness of lisdexamfetamine dimesylate (LDX) in the treatment of adults with attention-deficit/hyperactivity disorder (ADHD).

METHODS

Following a 4-week, placebo-controlled, double-blind trial, 349 adults with ADHD were enrolled into an open-label, single-arm study for up to 12 months. Treatment was initiated at 30 mg/day and titrated up to 70 mg/day at subsequent visits to achieve optimal effectiveness and tolerability. Safety assessments included adverse events inquiries, vital signs, and electrocardiograms while the primary effectiveness assessment was the ADHD Rating Scale (ADHD-RS) total score.

RESULTS

A total of 191 (54.7%) subjects completed the study. The most common treatment-emergent adverse events (TEAEs) were upper respiratory tract infection (21.8%), insomnia (19.5%), headache (17.2%), dry mouth (16.6%), decreased appetite (14.3%), and irritability (11.2%). Most TEAEs were mild to moderate in severity. At endpoint, small but statistically significant increases in pulse and blood pressure were noted. Significant improvements in mean ADHD-RS total scores were observed at week 1 and sustained throughout the study (P < .0001 at all postbaseline visits). At endpoint, the mean improvement from baseline ADHD-RS total score was 24.8 (P < .0001).

CONCLUSIONS

LDX demonstrated a safety profile consistent with long-acting stimulant use and provided continued effectiveness in adults with ADHD for up to 12 months.

College students with attention-deficit/hyperactivity disorder

As more students with attention-deficit/hyperactivity disorder attend college, studies are emerging that reveal problems in psychosocial and academic functioning. Substance use may magnify deficits in self-regulation. Recommendations are made for comprehensive assessment; however, the usual diagnostic categories may not be developmentally relevant. Students who are identified benefit from medication and nonmedication interventions, strategy support, and accommodations.

The neuropharmacology of ADHD drugs in vivo: insights on efficacy and safety

Results from in vivo techniques, especially intracerebral microdialysis in freely-moving rats, have provided insights into potential mechanisms responsible for the efficacy and safety of catecholaminergic drugs for ADHD treatment. The drugs reviewed come from distinct pharmacological classes: psychostimulant releasing agents, eg d-amphetamine; psychostimulant reuptake inhibitors, eg dl-threo-methylphenidate (dl-MPH), and non-stimulant reuptake inhibitors, eg atomoxetine. Psychostimulants, which currently deliver the best efficacy in treating ADHD, exhibit the following characteristics on extraneuronal catecholamine concentrations in rodent brain in vivo: 1) They enhance the efflux and function of both noradrenaline and dopamine in the central nervous system. 2) The increase of dopamine efflux that they produce is not limited to cortical regions. 3) They have a rapid onset of action with no ceiling on drug effect. d-Amphetamine has a mechanism independent of neuronal firing rate, displacing intraneuronal stores of catecholamines, delaying their reuptake and inhibiting catabolism by monoamine oxidase. dl-MPH has an enigmatic, extraneuronal action that is neuronal firing rate-dependent and reuptake transporter-mediated, yet paradoxically, almost as powerful as that of d-amphetamine. In safety terms, these powerful catecholaminergic effects also make the psychostimulants liable for abuse. Since efficacy and safety derive from the same pharmacological mechanisms, it has not yet been possible to separate these two components. However, the development of once-daily psychostimulant formulations and a prodrug, lisdexamfetamine, has improved patient compliance and markedly reduced scope for their diversion/abuse. This review will discuss the in vivo pharmacological profiles of approved catecholaminergic drugs for treatment of ADHD and implications for their clinical efficacy and abuse liability.

Occupational outcome in adult ADHD: impact of symptom profile, comorbid psychiatric problems, and treatment: a cross-sectional study of 414 clinically diagnosed adult ADHD patients

OBJECTIVE

To determine the effects of symptom profile, comorbid psychiatric problems, and treatment on occupational outcome in adult ADHD patients.

METHOD

Adult ADHD patients (N = 414) responded to questionnaires rating past and present symptoms of ADHD, comorbid conditions, treatment history, and work status.

RESULTS

Of the patients, 24% reported being in work, compared to 79% in a population-based control group (N = 359). Combined subtype of ADHD, substance abuse, and a reported history of depression or anxiety were correlated with being out of work. Current and past medical treatment of ADHD was correlated with being in work. Logistic regression analyses showed that stimulant therapy during childhood was the strongest predictor for being in work as adults (odds ratio = 3.2, p = .014).

CONCLUSION

Early recognition and treatment of ADHD is a strong predictor of being in work as an adult, independently of comorbidity, substance abuse, and current treatment.

The impact of childhood ADHD on dropping out of high school in urban adolescents/ young adults

OBJECTIVE

To examine cognitive and psychosocial factors associated with high school dropout in urban adolescents with and without childhood ADHD.

METHOD

In a longitudinal study, 49 adolescents/young adults with childhood ADHD and 44 controls who either dropped out or graduated from high school are included. Risk factors examined as potential correlates of dropout were intelligence, reading skills, socioeconomic status, marijuana use, and paternal contact.

RESULTS

Lower IQ, reading ability, socioeconomic status, frequent marijuana use, and limited paternal contact significantly differentiated dropouts from graduates, irrespective of childhood ADHD. Follow-up analyses determined that IQ, marijuana use, and paternal contact independently contribute to the likelihood of dropout.

CONCLUSION

Selected cognitive and psychosocial factors appear independently associated with the likelihood of high school dropout irrespective of ADHD. Notably, childhood ADHD did not increase this risk, suggesting that previous reports of increased dropout because of ADHD may become negated in urban areas when matched with similar community controls.

Effect of lisdexamfetamine dimesylate on sleep in adults with attention-deficit/hyperactivity disorder

Background

Sleep problems are common in adults with attention-deficit/hyperactivity disorder (ADHD). This analysis aimed to evaluate the impact of lisdexamfetamine dimesylate (LDX) on sleep quality in adults with ADHD.

Methods

This 4-week, phase 3, double-blind, forced-dose escalation study of adults aged 18 to 55 years with ADHD randomized participants to receive placebo (n = 62), or 30 (n = 119), 50 (n = 117), or 70 (n = 122) mg/d LDX, taken once a day in the morning. The self-rated Pittsburgh Sleep Quality Index (PSQI) was administered at baseline and at week 4 to assess sleep quality. The PSQI global score assesses 7 sleep components (subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction) each scored from 0 (no difficulty) to 3 (severe difficulty).

Results

The mean baseline PSQI global score was 5.8 for LDX and 6.3 for placebo (P = .19) indicating poor overall sleep quality. At endpoint, least squares (LS) mean change from baseline was -0.8 for LDX vs -0.5 for placebo (P = .33). The daytime functioning component showed significant improvement in LS mean change at endpoint for LDX compared with placebo (LDX -0.4 vs placebo 0.0, P = .0001). LS mean changes for the other 6 PSQI components did not significantly differ from placebo. Sleep-related treatment-emergent adverse events with an incidence ≥2% in the active treatment and placebo groups, respectively, were insomnia (19.3% and 4.8%), initial insomnia (5.0% and 3.2%), middle insomnia (3.6% and 0%), sleep disorder (0.6% and 3.2%), somnolence (0.3% and 3.2%), and fatigue (4.7% and 4.8%), and were generally mild or moderate in severity.

Conclusion

For most subjects, LDX was not associated with an overall worsening of sleep quality and significantly improved daytime functioning in adults with ADHD.

Trial Registration

clinicaltrials.gov Identifier: NCT00334880

Neurocognitive function in attention-deficit-hyperactivity disorder with and without comorbid disruptive behaviour disorders

OBJECTIVE

The aim of the present study was to examine the effect of comorbid oppositional defiant disorder (ODD) and conduct disorder (CD) on (i) symptom levels in attention-deficit-hyperactivity disorder (ADHD) and (ii) the relationship between neurocognitive impairment and ADHD symptom severity.

METHOD

A total of 200 6-12-year-old children with DSM-IV ADHD, combined type (ADHD-CT) were identified in a specialist ADHD clinic in metropolitan Melbourne. From this initial group, 23 were identified with ADHD without ODD/CD (ADHD alone), 22 had ADHD and ODD and 20 had ADHD and CD. All the children were medication naive. Twenty-five healthy control children were also recruited from local primary schools. The four groups did not differ in age, gender or full-scale IQ. A cross-sectional study of parent- and teacher-reported ADHD and externalizing symptoms, spatial span, spatial working memory, visuospatial memory, spatial recognition, spatial planning and behavioural inhibition was completed.

RESULTS

Parent-reported externalizing symptoms were higher in the ADHD + CD and ADHD + ODD groups compared to the ADHD alone group. There were no differences in neurocognitive function between children with ADHD-CT with and without ODD or CD. All the ADHD groups, however, performed worse than the healthy control group. Further, worse spatial span, spatial working memory and delayed matching to sample performance were associated with increased teacher-reported ADHD symptoms in the ADHD alone group. Also, worse spatial working memory performance was associated with increased teacher-reported ADHD symptoms in the ADHD + CD group.

CONCLUSIONS

ADHD symptom severity is associated with the magnitude of impairment in executive functions in children with ADHD alone, but these relationships can be obscured by the presence of comorbid disruptive disorders. Children with ADHD + CD may demonstrate similar associations to children with ADHD alone, suggesting a similar underlying dysfunction. ADHD + ODD, however, may be better understood as a maladaptive response to the abnormal behaviours and neurocognitive functions in ADHD.

Attention deficit hyperactivity disorder (ADHD): gender- and age-related differences in neurocognition

BACKGROUND

Despite the growing recognition that the clinical symptom characteristics associated with attention deficit hyperactivity disorder (ADHD) persist into adulthood in a high proportion of subjects, little is known about the persistence of neurocognitive deficits in ADHD. The objective was twofold: (1) to conduct a meta-analysis of neuropsychological studies to characterize attentional performance in subjects with adult ADHD by examining differences in ADHD versus normal control subjects; and (2) to investigate whether these differences vary as a function of age and gender.

METHOD

Twenty-five neuropsychological studies comparing subjects with adult ADHD and healthy controls were evaluated. Statistical effect size was determined to characterize the difference between ADHD and control subjects. Meta-regression analysis was applied to investigate whether the difference between ADHD and control subjects varied as a function of age and gender across studies.

RESULTS

Tests measuring focused and sustained attention yielded an effect size with medium to large magnitude whereas tests of simple attention resulted in a small to medium effect size in terms of poorer attention functioning of ADHD subjects versus controls. On some of the measures (e.g. Stroop interference), a lower level of attention functioning in the ADHD group versus the controls was associated with male gender.

CONCLUSIONS

Adult ADHD subjects display significantly poorer functioning versus healthy controls on complex but not on simple tasks of attention, and the degree of impairment varies with gender, with males displaying a higher level of impairment.

Substance use, trait measures, and subjective response to nicotine in never-smokers stratified on parental smoking history and sex

INTRODUCTION

Male and female never-smokers stratified on parental history of smoking were tested for possible differences in susceptibility to the hedonic effects of nicotine.

METHODS

We recruited nicotine-exposed never-smokers with two never-smoking biological parents (PH-) or two ever-smoking biological parents (PH+). After completing a baseline assessment battery focusing on conditions or behaviors associated with smoking, participants were tested for subjective and hedonic effects in response to administration of three different nicotine doses (0.0, 0.5, and 1.0 mg) via nasal spray. Physiological and biochemical reactivity also was monitored.

RESULTS

PH+ were significantly more likely to report having experienced a "buzz" upon early smoking experimentation and to have histories of alcohol abuse and alcoholism; they also scored higher on disordered eating. In response to nicotine dosing, PH+ reported an increase in depressed mood, compared with a minimal response in PH-, in keeping with our expectation that nicotine would have more pronounced effects in PH+. Regardless of parental history, women reported experiencing greater anxiety in response to the highest nicotine dose, compared with men.

DISCUSSION

Further exploration in larger samples, using more stringent selection criteria, a wider range of measures, and a less aversive dosing method, may provide a full test of the possible utility of the parental history model for illuminating biobehavioral mechanisms underlying response to nicotine. Also important would be broadening the scope of inquiry to include comparisons with ever-smokers to determine what protected PH+ from becoming smokers, despite the presence of factors that might be expected to decrease resilience and increase susceptibility.

Constitutional mechanisms of vulnerability and resilience to nicotine dependence

The core nature of nicotine dependence is evident in wide variations in how individuals become and remain smokers. Individuals with pre-existing behavioral traits are more likely to develop nicotine dependence and experience difficulty when attempting to quit. Many molecular factors likely contribute to individual variations in the development of nicotine dependence and behavioral traits in complex manners. However, the identification of such molecules has been hampered by the phenotypic complexity of nicotine dependence and the complex ways molecules affect elements of nicotine dependence. We hypothesize that nicotine dependence is, in part, a result of interactions between nicotine and pre-existing behavioral traits. This perspective suggests that the identification of the molecular bases of such pre-existing behavioral traits will contribute to the development of effective methods for reducing smoking dependence and for helping smokers to quit.

The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study

OBJECTIVES

To determine any long-term effects, 6 and 8 years after childhood enrollment, of the randomly assigned 14-month treatments in the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA; N = 436); to test whether attention-deficit/hyperactivity disorder (ADHD) symptom trajectory through 3 years predicts outcome in subsequent years; and to examine functioning level of the MTA adolescents relative to their non-ADHD peers (local normative comparison group; N = 261).

METHOD

Mixed-effects regression models with planned contrasts at 6 and 8 years tested a wide range of symptom and impairment variables assessed by parent, teacher, and youth report.

RESULTS

In nearly every analysis, the originally randomized treatment groups did not differ significantly on repeated measures or newly analyzed variables (e.g., grades earned in school, arrests, psychiatric hospitalizations, other clinically relevant outcomes). Medication use decreased by 62% after the 14-month controlled trial, but adjusting for this did not change the results. ADHD symptom trajectory in the first 3 years predicted 55% of the outcomes. The MTA participants fared worse than the local normative comparison group on 91% of the variables tested.

CONCLUSIONS

Type or intensity of 14 months of treatment for ADHD in childhood (at age 7.0-9.9 years) does not predict functioning 6 to 8 years later. Rather, early ADHD symptom trajectory regardless of treatment type is prognostic. This finding implies that children with behavioral and sociodemographic advantage, with the best response to any treatment, will have the best long-term prognosis. As a group, however, despite initial symptom improvement during treatment that is largely maintained after treatment, children with combined-type ADHD exhibit significant impairment in adolescence. Innovative treatment approaches targeting specific areas of adolescent impairment are needed.

Positive association between attention-deficit/ hyperactivity disorder medication use and academic achievement during elementary school

OBJECTIVE

Approximately 4.4 million (7.8%) children in the United States have been diagnosed with attention-deficit/hyperactivity disorder, and 56% of affected children take prescription medications to treat the disorder. Attention-deficit/hyperactivity disorder is strongly linked with low academic achievement, but the association between medication use and academic achievement in school settings is largely unknown. Our objective was to determine if reported medication use for attention-deficit/hyperactivity disorder is positively associated with academic achievement during elementary school.

METHOD

To estimate the association between reported medication use and standardized mathematics and reading achievement scores for a US sample of 594 children with attention-deficit/hyperactivity disorder, we used 5 survey waves between kindergarten and fifth grade from the nationally representative Early Childhood Longitudinal Study--Kindergarten Class of 1998-1999 to estimate a first-differenced regression model, which controlled for time-invariant confounding variables.

RESULTS

Medicated children had a mean mathematics score that was 2.9 points higher than the mean score of unmedicated peers with attention-deficit/hyperactivity disorder. Children who were medicated for a longer duration (at >2 waves) had a mean reading score that was 5.4 points higher than the mean score of unmedicated peers with attention-deficit/hyperactivity disorder. The medication-reading association was lower for children who had an individualized education program than for those without such educational accommodation.

CONCLUSIONS

The finding of a positive association between medication use and standardized mathematics and reading test scores is important, given the high prevalence of attention-deficit/hyperactivity disorder and its association with low academic achievement. The 2.9-point mathematics and 5.4-point reading score differences are comparable with score gains of 0.19 and 0.29 school years, respectively, but these gains are insufficient to eliminate the test-score gap between children with attention-deficit/hyperactivity disorder and those without the disorder. Long-term trials are needed to better understand the relationship between medication use and academic achievement.

Adult ADHD and comorbid depression: A consensus-derived diagnostic algorithm for ADHD

OBJECTIVE

Many patients present to their physician with depression as their primary symptom. However, depression may mask other comorbid disorders. This article presents diagnostic criteria and treatment recommendations (and monitoring) pertaining to the diagnosis of adult attention deficit hyperactivity disorder (ADHD), which may be missed in patients who present with depressive symptoms, or major depressive disorder (MDD). Other co-occurring conditions such as anxiety, substance use, and bipolar disorder are briefly discussed.

METHODS

A panel of psychiatrist-clinicians with expertise in the area of child and adolescent ADHD and mood disorders, adult mood disorders, and adult ADHD was convened. A literature search for recommendations on the diagnosis and treatment of co-occurring conditions (MDD, anxiety symptoms, and substance use) with adult ADHD was performed. Based on this, and the panel's clinical expertise, the authors developed a diagnostic algorithm and recommendations for the treatment of adult ADHD with co-occurring MDD.

RESULTS

Little information exists to assist clinicians in diagnosing ADHD co-occurring with other disorders such as MDD. A three-step process was developed by the panel to aid in the screening and diagnosis of adult ADHD. In addition, comorbid MDD, bipolar disorder, anxiety symptoms, substance use and cardiovascular concerns regarding stimulant use are discussed.

CONCLUSION

This article provides clinicians with a clinically relevant overview of the literature on comorbid ADHD and depression and offers a clinically useful diagnostic algorithm and treatment suggestions.

Association between smoking and retrospectively reported attention-deficit/hyperactivity disorder symptoms in a large sample of new mothers

INTRODUCTION

This study investigated the association between retrospectively reported attention-deficit/hyperactivity disorder (ADHD) symptoms experienced during childhood and five cigarette smoking-related outcomes in adulthood.

METHODS

A large sample (N = 1,117) of new mothers participating in an ongoing longitudinal study completed retrospective reports of their childhood ADHD symptomatology, as well as concurrent and retrospective reports of their smoking behavior. Linear regression models tested the association between ADHD symptomatology and smoking outcomes.

RESULTS

Childhood ADHD symptomatology was predictive of the number of cigarettes smoked per day currently and during pregnancy, as well as the age at onset of smoking. We found nonlinear associations between hyperactive-impulsive symptoms and the number of cigarettes smoked per day in pregnancy, as well as between inattentive symptoms and the number of cigarettes smoked per day currently. Women who retrospectively reported intermediate levels of ADHD symptoms during their childhood reported smoking more cigarettes per day than women who reported low or high levels of ADHD symptoms during childhood. We also found multiplicative relationship between inattentive and hyperactive-impulsive symptoms, such that inattentive symptoms were predictive of an earlier age at smoking onset only when hyperactive-impulsive symptoms were low; moreover, the magnitude of this association was stronger for Black relative to White women.

DISCUSSION

These findings demonstrate the importance of considering differential effects of ADHD symptoms and smoking outcomes as a function of sex and race. They also represent a potentially indirect means through which women who have even a moderate childhood history of ADHD symptomatology may create a set of circumstances that compromise the health and well-being of their own children.

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.

Comparison of symptomatic versus functional changes in children and adolescents with ADHD during randomized, double-blind treatment with psychostimulants, atomoxetine, or placebo

BACKGROUND

This meta-analysis was designed to determine the relationship between reduction of attention-deficit/hyperactivity disorder (ADHD) symptoms and improvement in functioning by examining short-term changes in functional and symptomatic scores in children and adolescents with ADHD.

METHODS

Search of atomoxetine's clinical trial database identified four studies involving a symptomatic measure, the ADHD Rating Scale-IV-Parent Version:Investigator-administered and -scored (ADHDRS-IV-Parent:Inv), and a functional measure, the Life Participation Scale for ADHD (LPS).

RESULTS

Correlation analysis revealed a moderate-to-strong association between changes in the LPS total versus ADHDRS-IV-Parent:Inv total (r: -.68). The LPS Self-control subscale showed higher correlations than the Happy/Social subscale with the symptomatic measures. Regression analysis also showed high sensitivity for functional measures to changes in symptom severity. Stratified analysis of mean changes in ADHDRS-IV-Parent:Inv scores corresponding to standardized changes in LPS functional scores indicated that a threshold reduction of 16-18 points on the ADHDRS-IV-Parent:Inv total score was needed for functional improvements to become evident.

CONCLUSIONS

Subjects' symptomatic improvements appear to be reflected in improvements in their social and behavioral function as measured by the LPS. These initial findings warrant verification by replication with other outcome measures.

Academic performance in ADHD when controlled for comorbid learning disorders, family income, and parental education in Brazil

OBJECTIVE

Scholastic achievement in a nonclinical sample of ADHD children and adolescents was evaluated taking into consideration variables such as comorbid learning disorders, family income, and parental education which may also be associated with poor academic performance.

METHOD

After screening for ADHD in 396 students, the authors compared academic performance of 26 ADHD individuals and 31 controls paired for gender, age, and intelligence level considering both mathematics and Portuguese language scores. Learning disorders were investigated and the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV ) criteria were met using structured interviews.

RESULTS

The prevalence of academic underachievement was 2.98 times higher in students with ADHD, the most frequent subtype being predominantly inattentive. Parental educational level, family income, and comorbid learning disorders could not explain the discrepancies between ADHD students and controls.

CONCLUSIONS

ADHD seems to be associated with poor academic performance even in the absence of comorbid learning disorders, lower family income, and parental educational level.

Adolescents with childhood ADHD and comorbid disruptive behavior disorders: aggression, anger, and hostility

This study examined the self-reported expression of overt aggressive behaviors and covert emotional and cognitive processes in adolescents diagnosed with ADHD and comorbid disruptive behavior disorders (DBDs) during childhood.

METHODS

Participants were a clinically referred sample of 85 individuals diagnosed with ADHD, initially recruited in the early to mid 1990s when they were 7-11 years of age. At that time, 44 (52%) met criteria for a comorbid diagnosis of ODD and an additional 22 (26%) met criteria for a comorbid diagnosis of CD. Approximately 10 years later, these youth, along with an age-matched comparison sample (n=83), were re-evaluated to assess a wide array of outcomes including physical and verbal aggression, anger, and hostility.

RESULTS

Individuals diagnosed with ADHD + CD in childhood reported elevated levels of physical aggression when compared to Controls and the ADHD-only group. Individuals diagnosed with ADHD + ODD had elevated levels of verbal aggression compared to Controls. Additionally, both comorbid groups experienced significantly greater amounts of anger, but not hostility, as compared to Controls. Importantly, the persistence of ADHD symptoms into adolescence accounted for most group differences in verbal aggression and anger at follow-up, but not physical aggression, which was accounted for by childhood CD.

CONCLUSION

Adolescents diagnosed with ADHD and comorbid disruptive behavior disorders during childhood report high levels of aggression associated with increased emotionality in the form of anger, but not hostile cognitions. These findings suggest that in addition to inattention and hyperactivity/impulsivity, emotional dysregulation may be an important component of ADHD, particularly as it presents in adolescence.

Untreated ADHD in adults: are there sex differences in symptoms, comorbidity, and impairment?

OBJECTIVE

To analyze sex differences among adult, never-treated patients referred for central stimulant treatment of ADHD.

METHOD

Data for 600 consecutive patients from northern Norway referred for evaluation by an expert team during 7 years were analyzed. General background information, diagnostic and social history, and symptom profiles were compared between previously never-treated men and women.

RESULTS

The sex ratio was skewed. Of the previously untreated patients, more than 20% fell outside society's ordinary vocational activities or social benefit system. Most patients had the combined form, one third the inattentive type, and only 2% the hyperactive/impulsive subtype. Abuse and criminality were more common among men, and affective, eating, and somatization disorders were more common among women. Otherwise few sex differences were found.

CONCLUSION

AD/HD symptom intensity and subtypes did not differ between the sexes and was unrelated to age. Symptom intensity was linked with criminality, abuse, and other psychiatric problems, differentially for the two sexes.

Childhood predictors of adult attention-deficit/hyperactivity disorder: results from the World Health Organization World Mental Health Survey Initiative

BACKGROUND

Although it is known that childhood attention-deficit/hyperactivity disorder (ADHD) often persists into adulthood, childhood predictors of this persistence have not been widely studied.

METHODS

Childhood history of ADHD and adult ADHD were assessed in 10 countries in the World Health Organization World Mental Health Surveys. Logistic regression analysis was used to study associations of retrospectively reported childhood risk factors with adult persistence among the 629 adult respondents with childhood ADHD. Risk factors included age; sex; childhood ADHD symptom profiles, severity, and treatment; comorbid child/adolescent DSM-IV disorders; childhood family adversities; and child/adolescent exposure to traumatic events.

RESULTS

An average of 50% of children with ADHD (range: 32.8%-84.1% across countries) continued to meet DSM-IV criteria for ADHD as adults. Persistence was strongly related to childhood ADHD symptom profile (highest persistence associated with the attentional plus impulsive-hyperactive type, odds ratio [OR]=12.4, compared with the lowest associated with the impulsive-hyperactive type), symptom severity (OR=2.0), comorbid major depressive disorder (MDD; OR=2.2), high comorbidity (>or=3 child/adolescent disorders in addition to ADHD; OR=1.7), paternal (but not maternal) anxiety mood disorder (OR=2.4), and parental antisocial personality disorder (OR=2.2). A multivariate risk profile of these variables significantly predicts persistence of ADHD into adulthood (area under the receiving operator characteristic curve=.76).

CONCLUSIONS

A substantial proportion of children with ADHD continue to meet full criteria for ADHD as adults. A multivariate risk index comprising variables that can be assessed in adolescence predicts persistence with good accuracy.

Profiles of service utilization and the resultant economic impact in preschoolers with attention deficit/hyperactivity disorder

OBJECTIVE

To examine whether preschool children with Attention deficit/hyperactivity disorder (ADHD) utilize more speech and language therapy (ST), occupational therapy (OT), and physical therapy (PT) services and are more likely to be placed in special education (SPED) classrooms as compared to their peers. Corresponding financial consequences were also examined.

METHODS

The amount of ST, OT, and PT, as well as SPED placements, was examined in 3- and 4-year-old children with and without ADHD (n = 109 and n = 97, respectively) during the baseline portion of an ongoing, 5-year longitudinal study. Costs for individual services and aggregate cost were determined per child and compared across groups.

RESULTS

Preschool children with ADHD were more likely to receive individual and multiple services. Higher rates of service utilization translated into increased costs for each individual service with the exception of PT.

CONCLUSIONS

A comprehensive understanding of service utilization in the early years of development is important in addressing the increased service use in the preschool years and assist in guiding allocation of resources.

Global issues related to the impact of untreated attention-deficit/hyperactivity disorder from childhood to young adulthood

Attention-deficit/hyperactivity disorder (ADHD) is a common, chronic, and costly disorder, with an impact that can span from preschool into adulthood. There are safe and effective therapies that can manage and help prevent many of the associated negative outcomes of ADHD, but treatment rates are far from optimal and considerable obstacles exist in achieving satisfactory treatment adherence. Individuals with untreated ADHD, their families, and other caregivers must be made aware of the impact that this disorder may have on them at every stage of life and, correspondingly, the improved outcomes that can be achieved with the successful management of ADHD.

Feasibility and preliminary efficacy of an after-school program for middle schoolers with ADHD: a randomized trial in a large public middle school

OBJECTIVE

This pilot study tests the feasibility and preliminary efficacy of an after-school treatment program for middle schoolers with ADHD using a randomized clinical trial design.

METHOD

A total of 23 students with ADHD (25% female, 48% African American) from a large public middle school were randomly assigned to a 10-week program or to community comparison. Manualized treatment targeted educational, social, and recreational skills, homework completion, and school and home behavior. Parents participated.

RESULTS

Recruitment and randomization targets were easily met (87% completion). Parent and teacher satisfaction was positive. Small to medium treatment effects resulted despite greater medication use in the control group, with improvements in functioning for the program-treated youth or absence of deterioration relative to the comparison group.

CONCLUSION

Despite testing an abbreviated version of the after-school program (< 5 months), this study reveals feasibility and palatability for this intervention and modest beneficial effects on behavioral and academic outcomes.

Impact of attention-deficit/hyperactivity disorder on the patient and family: results from a European survey

BACKGROUND

Children with attention-deficit/hyperactivity disorder (ADHD) often experience problems with education, interaction with others and emotional disturbances. Families of ADHD children also suffer a significant burden, in terms of strain on relationships and reduced work productivity. This parent survey assessed daily life for children with ADHD and their families.

METHOD

This pan-European survey involved the completion of an on-line questionnaire by parents of children (6-18 years) with ADHD (ADHD sample) and without ADHD (normative population sample). Parents were questioned about the impact of their child's ADHD on everyday activities, general behaviour and family relationships.

RESULTS

The ADHD sample comprised 910 parents and the normative population sample 995 parents. 62% of ADHD children were not currently receiving medication; 15% were receiving 6-8 hour stimulant medication and 23% 12-hour stimulant medication. Compared with the normative population sample, parents reported that ADHD children consistently displayed more demanding, noisy, disruptive, disorganised and impulsive behaviour. Significantly more parents reported that ADHD children experienced challenges throughout the day, from morning until bedtime, compared with the normative population sample. Parents reported that children with ADHD receiving 12-hour stimulant medication experienced fewer challenges during early afternoon and late afternoon/early evening than children receiving 6-8 hour stimulant medication; by late evening and bedtime however, this difference was not apparent. ADHD was reported to impact most significantly on activities such as homework, family routines and playing with other children. All relationships between ADHD children and others were also negatively affected, especially those between parent and child (72% of respondents). Parents reported that more children with ADHD experienced a personal injury in the preceding 12 months, including those requiring the attention of healthcare professionals. Although 68% of parents were satisfied with their child's current treatment, 35-40% stated that their child's ADHD symptoms needed to be more effectively treated during the afternoon and evening.

CONCLUSION

This parent survey highlights the breadth of problems experienced by ADHD children and the impact throughout the day on both activities and relationships. Therefore, there is a need for treatment approaches that take into account the 24-hour impact of the disorder and include all-day coverage with effective medication.