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Roessner V, Eichele H, Stern JS, Skov L, Rizzo R, Debes NM, Nagy P, Cavanna AE, Termine C, Ganos C, Münchau A, Szejko N, Cath D, Müller-Vahl KR, Verdellen C, Hartmann A, Rothenberger A, Hoekstra PJ, Plessen KJ. European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part III: pharmacological treatment. Eur Child Adolesc Psychiatry 2022; 31:425-441. [PMID: 34757514 PMCID: PMC8940878 DOI: 10.1007/s00787-021-01899-z] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 10/24/2021] [Indexed: 12/18/2022]
Abstract
In 2011, the European Society for the Study of Tourette Syndrome (ESSTS) published the first European guidelines for Tourette Syndrome (TS). We now present an update of the part on pharmacological treatment, based on a review of new literature with special attention to other evidence-based guidelines, meta-analyses, and randomized double-blinded studies. Moreover, our revision took into consideration results of a recent survey on treatment preferences conducted among ESSTS experts. The first preference should be given to psychoeducation and to behavioral approaches, as it strengthens the patients' self-regulatory control and thus his/her autonomy. Because behavioral approaches are not effective, available, or feasible in all patients, in a substantial number of patients pharmacological treatment is indicated, alone or in combination with behavioral therapy. The largest amount of evidence supports the use of dopamine blocking agents, preferably aripiprazole because of a more favorable profile of adverse events than first- and second-generation antipsychotics. Other agents that can be considered include tiapride, risperidone, and especially in case of co-existing attention deficit hyperactivity disorder (ADHD), clonidine and guanfacine. This view is supported by the results of our survey on medication preference among members of ESSTS, in which aripiprazole was indicated as the drug of first choice both in children and adults. In treatment resistant cases, treatment with agents with either a limited evidence base or risk of extrapyramidal adverse effects might be considered, including pimozide, haloperidol, topiramate, cannabis-based agents, and botulinum toxin injections. Overall, treatment of TS should be individualized, and decisions based on the patient's needs and preferences, presence of co-existing conditions, latest scientific findings as well as on the physician's preferences, experience, and local regulatory requirements.
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Affiliation(s)
- Veit Roessner
- Department of Child and Adolescent Psychiatry, TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - Heike Eichele
- Department of Biological and Medical Psychology, Faculty of Psychology, University of Bergen, Bergen, Norway , Regional Resource Center for Autism, ADHD, Tourette Syndrome and Narcolepsy Western Norway, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Jeremy S. Stern
- Department of Neurology, St George’s Hospital, St George’s University of London, London, UK
| | - Liselotte Skov
- Paediatric Department, Herlev University Hospital, Herlev, Denmark
| | - Renata Rizzo
- Child and Adolescent Neurology and Psychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | | | - Péter Nagy
- Vadaskert Child Psychiatric Hospital and Outpatient Clinic, Budapest, Hungary
| | - Andrea E. Cavanna
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Cristiano Termine
- Child Neuropsychiatry Unit, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Christos Ganos
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Münchau
- Institute of Systems Motor Science, University of Lübeck, Lübeck, Germany
| | - Natalia Szejko
- Department of Neurology, Medical University of Warsaw, Warsaw, Poland ,Department of Bioethics, Medical University of Warsaw, Warsaw, Poland ,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT USA
| | - Danielle Cath
- Department of Psychiatry, University Medical Center Groningen, Rijks Universiteit Groningen, GGZ Drenthe Mental Health Institution, Assen, The Netherlands
| | - Kirsten R. Müller-Vahl
- Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Cara Verdellen
- PsyQ Nijmegen, Parnassia Group, Nijmegen, The Netherlands ,TicXperts, Heteren, The Netherlands
| | - Andreas Hartmann
- Department of Neurology, Sorbonne Université, Pitié-Salpetriere Hospital, Paris, France ,National Reference Center for Tourette Disorder, Pitié Salpetiere Hospital, Paris, France
| | - Aribert Rothenberger
- Clinic for Child and Adolescent Psychiatry and Psychotherapy, University Medical Center Gottingen, Gottingen, Germany
| | - Pieter J. Hoekstra
- Department of Child and Adolescent Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Kerstin J. Plessen
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland ,Child and Adolescent Mental Health Centre, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark
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Kis B, Lücke C, Abdel-Hamid M, Heßmann P, Graf E, Berger M, Matthies S, Borel P, Sobanski E, Alm B, Rösler M, Retz W, Jacob C, Colla M, Huss M, Jans T, van Elst LT, Müller HHO, Philipsen A. Safety Profile of Methylphenidate Under Long-Term Treatment in Adult ADHD Patients - Results of the COMPAS Study. PHARMACOPSYCHIATRY 2020; 53:263-271. [PMID: 33017854 DOI: 10.1055/a-1207-9851] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The Comparison of Methylphenidate and Psychotherapy in adult ADHD Study (COMPAS) was a prospective, randomized multicenter clinical trial, comparing methylphenidate (MPH) with placebo (PLAC) in combination with cognitive behavioral group psychotherapy (GPT) or individual clinical management (CM) over the period of 1 year. Here, we report results on treatment safety. METHODS MPH and PLAC were flexibly dosed. Among 433 randomized patients, adverse events (AEs) were documented and analyzed on an "as received" basis during week 0-52. Electrocardiogram data were recorded at baseline and week 24. RESULTS Comparing 205 patients who received ≥1 dose of MPH with 209 patients who received PLAC, AEs occurring significantly more frequently in the MPH group were decreased appetite (22 vs. 3.8%), dry mouth (15 vs. 4.8%), palpitations (13 vs. 3.3%), gastrointestinal infection (11 vs. 4.8%), agitation (11 vs. 3.3%), restlessness (10 vs. 2.9%), hyperhidrosis, tachycardia, weight decrease (all 6.3 vs. 1.9%), depressive symptom, influenza (both 4.9 vs. 1.0%), and acute tonsillitis (4.4 vs. 0.5%). Syncope occurred significantly more often in the PLAC group (2.4 vs. 0%). Clinically relevant ECG changes occurred very rarely in both groups. Serious AEs were rare and without a significant group difference. The comparison of 206 patients treated with GPT versus 209 patients who received CM revealed no major differences. Serious AE classified as psychiatric occurred in 5 cases in the CM group and in 1 case in the GPT group. CONCLUSION In this so far longest-running clinical trial, methylphenidate treatment was safe and well-tolerated.
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Affiliation(s)
- Bernhard Kis
- Department of Psychiatry, Psychotherapy and Psychosomatics, St. Elisabeth Hospital Niederwenigern, Contilia Group, Hattingen, Germany.,Department of Psychiatry and Psychotherapy, University Medical Center, Göttingen, Germany.,LVR-Hospital Essen, Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
| | - Caroline Lücke
- Department of Psychiatry and Psychotherapy - University of Bonn, Bonn, Germany
| | - Mona Abdel-Hamid
- Department of Psychiatry and Psychotherapy, University Medical Center, Göttingen, Germany.,LVR-Hospital Essen, Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
| | - Philipp Heßmann
- Department of Psychiatry and Psychotherapy, University Medical Center, Göttingen, Germany
| | - Erika Graf
- Institute of Medical Biometry and Statistics, Clinical Trials Unit and Medical Faculty, University Medical Center - University of Freiburg, Freiburg, Germany
| | - Mathias Berger
- Department of Psychiatry and Psychotherapy, Medical Faculty, University Medical Center - University of Freiburg, Freiburg, Germany
| | - Swantje Matthies
- Department of Psychiatry and Psychotherapy, Medical Faculty, University Medical Center - University of Freiburg, Freiburg, Germany
| | - Patricia Borel
- Department of Psychiatry and Psychotherapy, Medical Faculty, University Medical Center - University of Freiburg, Freiburg, Germany
| | - Esther Sobanski
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Clinical Faculty Mannheim, University of Heidelberg, Mannheim, Germany.,Department of Child and Adolescent Psychiatry and Psychotherapy, University Medicine Mainz, Mainz, Germany
| | - Barbara Alm
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Clinical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Rösler
- Institute for Forensic Psychology and Psychiatry, Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - Wolfgang Retz
- Institute for Forensic Psychology and Psychiatry, Saarland University Faculty of Medicine, Homburg/Saar, Germany.,Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Christian Jacob
- Clinic for Psychiatry and Psychotherapy, Medius Clinic, Kirchheim, Germany
| | - Michael Colla
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Michael Huss
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Medicine Mainz, Mainz, Germany
| | - Thomas Jans
- University Hospital of Würzburg, Center of Mental Health, Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Würzburg, Germany
| | - Ludger Tebartz van Elst
- Department of Psychiatry and Psychotherapy, Medical Faculty, University Medical Center - University of Freiburg, Freiburg, Germany
| | - Helge H O Müller
- Witten/Herdecke University, Faculty of Health/School of Medicine, Integrative Psychiatry and Psychotherapy, Witten, Germany
| | - Alexandra Philipsen
- Department of Psychiatry and Psychotherapy - University of Bonn, Bonn, Germany
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Kim YS, Choi J, Yoon BE. Neuron-Glia Interactions in Neurodevelopmental Disorders. Cells 2020; 9:cells9102176. [PMID: 32992620 PMCID: PMC7601502 DOI: 10.3390/cells9102176] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/24/2020] [Accepted: 09/24/2020] [Indexed: 12/12/2022] Open
Abstract
Recent studies have revealed synaptic dysfunction to be a hallmark of various psychiatric diseases, and that glial cells participate in synapse formation, development, and plasticity. Glial cells contribute to neuroinflammation and synaptic homeostasis, the latter being essential for maintaining the physiological function of the central nervous system (CNS). In particular, glial cells undergo gliotransmission and regulate neuronal activity in tripartite synapses via ion channels (gap junction hemichannel, volume regulated anion channel, and bestrophin-1), receptors (for neurotransmitters and cytokines), or transporters (GLT-1, GLAST, and GATs) that are expressed on glial cell membranes. In this review, we propose that dysfunction in neuron-glia interactions may contribute to the pathogenesis of neurodevelopmental disorders. Understanding the mechanisms of neuron-glia interaction for synapse formation and maturation will contribute to the development of novel therapeutic targets of neurodevelopmental disorders.
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Affiliation(s)
- Yoo Sung Kim
- Department of Molecular Biology, Dankook University, Cheonan 31116, Korea; (Y.S.K.); (J.C.)
| | - Juwon Choi
- Department of Molecular Biology, Dankook University, Cheonan 31116, Korea; (Y.S.K.); (J.C.)
| | - Bo-Eun Yoon
- Department of Molecular Biology, Dankook University, Cheonan 31116, Korea; (Y.S.K.); (J.C.)
- Department of Nanobiomedical science, Dankook University, Cheonan 31116, Korea
- Correspondence: ; Tel.: +82-41-529-6085
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Abstract
Tourette's disorder (TD) is one of the five American Psychiatric Association's 2013 Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifications of tic disorders. Eponymously linked with the noted 19th century French physician, Gilles de la Tourette [1857-1904], this disorder is identified in 0.3% to 0.7% of the population. It is characterized as a familial neuropsychiatric condition with multiple motor tics and vocal tics (one or more) present for more than 1 year with varying severity. The underlying pathophysiology involves dysfunctional activity of the basal ganglia and circuitry of the frontal cortex as well as dorsolateral striatum deficits. Contributory factors include genetic features interacting with milieu influences. A number of comorbid disorders are seen including obsessive-compulsive disorder (OCD) and attention-deficit/hyperactivity disorder (ADHD). Concepts of management are considered including behavioral therapy and pharmacologic approaches with alpha-adrenoceptor agonists, atypical antipsychotics (AAs), haloperidol, pimozide and others. Other management includes botulinum injections and deep brain stimulation in adults.
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Affiliation(s)
- Donald E Greydanus
- Department of Pediatric and Adolescent Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
| | - Julia Tullio
- Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
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Greydanus DE, Cates KW, Sadigh N. Adverse effects of stimulant medications in children and adolescents: focus on drug abuse. Int J Adolesc Med Health 2019; 31:ijamh-2019-0175. [PMID: 31483757 DOI: 10.1515/ijamh-2019-0175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 08/12/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Donald E Greydanus
- Department of Pediatric and Adolescent Medicine, Western Michigan University, Homer Stryker MD School of Medicine, 1000 Oakland Drive, Kalamazoo, MI 49008-1284, USA
| | - Kevin W Cates
- Western Michigan University, Homer Stryker MD School of Medicine, Kalamazoo, MI, USA
| | - Nina Sadigh
- Western Michigan University, Homer Stryker MD School of Medicine, Kalamazoo, MI, USA
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Treatment strategies for ADHD: an evidence-based guide to select optimal treatment. Mol Psychiatry 2019; 24:390-408. [PMID: 29955166 DOI: 10.1038/s41380-018-0116-3] [Citation(s) in RCA: 134] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 04/20/2018] [Accepted: 05/14/2018] [Indexed: 12/12/2022]
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is a common and impairing disorder affecting children, adolescents, and adults. Several treatment strategies are available that can successfully ameliorate symptoms, ranging from pharmacological to dietary interventions. Due to the increasing range of available options, an informed selection or prioritization of treatments is becoming harder for clinicians. This review aims to provide an evidence-based appraisal of the literature on ADHD treatment, supplemented by expert opinion on plausibility. We outline proposed mechanisms of action of established pharmacologic and non-pharmacologic treatments, and we review targets of novel treatments. The most relevant evidence supporting efficacy and safety of each treatment strategy is discussed. We review the individualized features of the patient that should guide the selection of treatments in a shared decision-making continuum. We provide guidance for optimizing initiation of treatment and follow-up of patients in clinical settings.
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7
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Pozzi M, Carnovale C, Peeters GGAM, Gentili M, Antoniazzi S, Radice S, Clementi E, Nobile M. Adverse drug events related to mood and emotion in paediatric patients treated for ADHD: A meta-analysis. J Affect Disord 2018; 238:161-178. [PMID: 29883938 DOI: 10.1016/j.jad.2018.05.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 04/09/2018] [Accepted: 05/16/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND ADHD is frequently comorbid with anxiety and mood disorders, which may increase the severity of inattention and hyperactivity symptoms. Emotional symptoms (anxiety, irritability, mood lability) also affect patients without comorbidity or emerge as adverse drug events. The influence of ADHD drugs on emotional symptoms demands investigation to improve therapies. METHODS Systematic review of trials reporting adverse events in patients pharmacologically treated for ADHD. Meta-analysis of the occurrence of irritability, anxiety, apathy, reduced talk, sadness, crying, emotional lability, biting nails, staring, perseveration, euphoria. Meta-regression analysis. RESULTS Forty-five trials were meta-analysed. The most frequently reported outcomes were irritability, anxiety, sadness, and apathy. Methylphenidates, especially immediate-release formulations, were most studied; amphetamines were half as studied and were predominantly mixed amphetamine salts. Reports on atomoxetine were scant. Meta-analysis showed that methylphenidates reduced the risk of irritability, anxiety, euphoria, whereas they worsened the risk of apathy and reduced talk; amphetamines worsened the risk of emotional lability. Factors influencing risks were study year and design, patients' sex and age, drug dose and release formulation. LIMITATIONS Possible discrepancy between adverse events as indicated in clinical trials and as summarised herein. Confounding due to the aggregation of drugs into groups; uninvestigated sources of bias; incomplete lists of adverse events; lack of observations on self-injury. CONCLUSIONS Methylphenidates appeared safer than amphetamines, although younger patients and females may incur higher risks, especially with high-dose, immediate-release methylphenidates. Only atomoxetine holds a black-box warning, but amphetamines and methylphenidates also did not show a safe profile regarding mood and emotional symptoms.
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Affiliation(s)
- Marco Pozzi
- Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy.
| | - Carla Carnovale
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, 20157 Milan, Italy
| | - Gabriëlla G A M Peeters
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, 20157 Milan, Italy
| | - Marta Gentili
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, 20157 Milan, Italy
| | - Stefania Antoniazzi
- IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Sonia Radice
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, 20157 Milan, Italy
| | - Emilio Clementi
- Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy; Unit of Clinical Pharmacology, CNR Institute of Neuroscience, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, 20157 Milan, Italy.
| | - Maria Nobile
- Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy
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Osland ST, Steeves TDL, Pringsheim T. Pharmacological treatment for attention deficit hyperactivity disorder (ADHD) in children with comorbid tic disorders. Cochrane Database Syst Rev 2018; 6:CD007990. [PMID: 29944175 PMCID: PMC6513283 DOI: 10.1002/14651858.cd007990.pub3] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND This is an update of the original Cochrane Review published in Issue 4, 2011.Attention deficit hyperactivity disorder (ADHD) is the most prevalent of the comorbid psychiatric disorders that complicate tic disorders. Medications commonly used to treat ADHD symptoms include stimulants such as methylphenidate and amphetamine; non-stimulants, such as atomoxetine; tricyclic antidepressants; and alpha agonists. Alpha agonists are also used as a treatment for tics. Due to the impact of ADHD symptoms on the child with tic disorder, treatment of ADHD is often of greater priority than the medical management of tics. However, for many decades, clinicians have been reluctant to use stimulants to treat children with ADHD and tics for fear of worsening their tics. OBJECTIVES: To assess the effects of pharmacological treatments for ADHD in children with comorbid tic disorders on symptoms of ADHD and tics. SEARCH METHODS In September 2017, we searched CENTRAL, MEDLINE, Embase, and 12 other databases. We also searched two trial registers and contacted experts in the field for any ongoing or unpublished studies. SELECTION CRITERIA We included randomized, double-blind, controlled trials of any pharmacological treatment for ADHD used specifically in children with comorbid tic disorders. We included both parallel-group and cross-over study designs. DATA COLLECTION AND ANALYSIS We used standard methodological procedures of Cochrane, in that two review authors independently selected studies, extracted data using standardized forms, assessed risk of bias, and graded the overall quality of the evidence by using the GRADE approach. MAIN RESULTS We included eight randomized controlled trials (four of which were cross-over trials) with 510 participants (443 boys, 67 girls) in this review. Participants in these studies were children with both ADHD and a chronic tic disorder. All studies took place in the USA and ranged from three to 22 weeks in duration. Five of the eight studies were funded by charitable organizations or government agencies, or both. One study was funded by the drug manufacturer. The other two studies did not specify the source of funding. Risk of bias of included studies was low for blinding; low or unclear for random sequence generation, allocation concealment, and attrition bias; and low or high for selective outcome reporting. We were unable to combine any of the studies in a meta-analysis due to important clinical heterogeneity and unit-of-analysis issues.Several of the trials assessed multiple agents. Medications assessed included methylphenidate, clonidine, desipramine, dextroamphetamine, guanfacine, atomoxetine, and deprenyl. There was low-quality evidence for methylphenidate, atomoxetine, and clonidine, and very low-quality evidence for desipramine, dextroamphetamine, guanfacine and deprenyl in the treatment of ADHD in children with tics. All studies, with the exception of a study using deprenyl, reported improvement in symptoms of ADHD. Tic symptoms also improved in children treated with guanfacine, desipramine, methylphenidate, clonidine, and a combination of methylphenidate and clonidine. In one study, tics limited further dosage increases of methylphenidate. High-dose dextroamphetamine appeared to worsen tics in one study, although the length of this study was limited to three weeks. There was appetite suppression or weight loss in association with methylphenidate, dextroamphetamine, atomoxetine, and desipramine. There was insomnia associated with methylphenidate and dextroamphetamine, and sedation associated with clonidine. AUTHORS' CONCLUSIONS Following an updated search of potentially relevant studies, we found no new studies that matched our inclusion criteria and thus our conclusions have not changed.Methylphenidate, clonidine, guanfacine, desipramine, and atomoxetine appear to reduce ADHD symptoms in children with tics though the quality of the available evidence was low to very low. Although stimulants have not been shown to worsen tics in most people with tic disorders, they may, nonetheless, exacerbate tics in individual cases. In these instances, treatment with alpha agonists or atomoxetine may be an alternative. Although there is evidence that desipramine may improve tics and ADHD in children, safety concerns will likely continue to limit its use in this population.
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Affiliation(s)
- Sydney T Osland
- University of CalgaryDepartment of Pediatrics3280 Hospital Dr NWCalgaryAlbertaCanadaT0L0X0
| | - Thomas DL Steeves
- University of TorontoDepartment of Medicine, Division of NeurologySt Michael's Hospital55 Queen Street East, #906TorontoONCanadaM5C 1R6
| | - Tamara Pringsheim
- University of CalgaryDepartment of Clinical Neurosciences, Psychiatry, Pediatrics and Community Health SciencesMathison Centre for Mental Health Reseach and Education4th floor, TRW Building, 4D72, 3280 Hospital Drive NWCalgaryABCanadaT2N 4Z6
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Zhang Z, Yang C, Zhang LL, Yi Q, Liu B, Zeng J, Yu D. Pharmacotherapies to tics: a systematic review. Oncotarget 2018; 9:28240-28266. [PMID: 29963275 PMCID: PMC6021346 DOI: 10.18632/oncotarget.25080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 03/19/2018] [Indexed: 12/21/2022] Open
Abstract
The efficacy of all pharmacotherapies for patients suffering from tics were unclear. Literatures were searched from Medline, Embase, The Cochrane Library, and four Chinese databases. The primary efficacy outcome scale was defined as the Yale Global Tic Severity Scale (YGTSS). Overall estimates of pooled weighted mean difference (WMD) with 95% confidence interval (CI) were calculated for each outcome measure. A total of 53 trials were included. Meta-analysis suggested that alpha-2 adrenergic agonist agents and atypical antipsychotic agents were effective in improving tics, which included the maximum number of trials. Typical antipsychotic agents were associated with severer side-effects than alpha-2 adrenergic agonist agents. Besides, Traditional Chinese Medicine showed positive effects in YGTSS (NingDong Granule: WMD=-7.100, 95% CI, -10.430- -3.770; 5-Ling Granule: WMD=-11.300, 95% CI, -14.208- -8.392), while glutamate modulators (D-serine, N-Acetylcysteine and riluzole) might not be working. In summary, alpha-2 adrenergic agonist agents were associated with the optimal weigh between efficacy and safety. However, the significant factor of limited trials and sample sizes discounted these findings. Further better studies are necessary to ascertain them.
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Affiliation(s)
- Zuojie Zhang
- Department of Pharmacy, Evidence-Based Pharmacy Center, West China Second Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China.,West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Chunsong Yang
- Department of Pharmacy, Evidence-Based Pharmacy Center, West China Second Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Ling-Li Zhang
- Department of Pharmacy, Evidence-Based Pharmacy Center, West China Second Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Qiusha Yi
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Bo Liu
- Department of Pharmacy, Evidence-Based Pharmacy Center, West China Second Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Jing Zeng
- Department of Pharmacy, Evidence-Based Pharmacy Center, West China Second Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Dan Yu
- Department of Neurology, West China Second Hospital, Sichuan University, Chengdu, China
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Pringsheim T. Tic Severity and Treatment in Children: The Effect of Comorbid Attention Deficit Hyperactivity Disorder and Obsessive Compulsive Behaviors. Child Psychiatry Hum Dev 2017; 48:960-966. [PMID: 28289952 DOI: 10.1007/s10578-017-0718-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
While attention deficit hyperactivity disorder (ADHD) and obsessive compulsive disorder have been shown to have major impacts on quality of life in individuals with Tourette syndrome, there is comparatively little data on how the presence of these comorbidities influence tic severity and treatment. 114 children (mean age 10.25 years) were extensively clinically phenotyped at a single specialty clinic. While there was no difference in Yale Global Tic Severity Scale (YGTSS) scores in children with versus without ADHD, children with obsessive compulsive behaviors had significantly higher YGTSS scores (p = 0.008). There was a significant correlation between YGTSS scores and age (r = 0.344, p < 0.001). Children with ADHD were more likely to be treated for their tics within the first two years of diagnosis (OR 3.51, p = 0.009). As tic severity does not appear to be greater in children with ADHD, this association may relate to greater overall psychosocial impairment in children with this comorbidity.
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Affiliation(s)
- Tamara Pringsheim
- Department of Clinical Neurosciences, Psychiatry, Pediatrics and Community Health Sciences, Mathison Centre for Mental Health Research and Education, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
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Thienemann M, Murphy T, Leckman J, Shaw R, Williams K, Kapphahn C, Frankovich J, Geller D, Bernstein G, Chang K, Elia J, Swedo S. Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part I-Psychiatric and Behavioral Interventions. J Child Adolesc Psychopharmacol 2017; 27:566-573. [PMID: 28722481 PMCID: PMC5610394 DOI: 10.1089/cap.2016.0145] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE This article outlines the consensus guidelines for symptomatic treatment for children with Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) and Pediatric Autoimmune Neuropsychiatric Syndrome Associated with Streptococcal Infection (PANDAS). METHODS Extant literature on behavioral, psychotherapeutic, and psychopharmacologic treatments for PANS and PANDAS was reviewed. Members of the PANS Research Consortium pooled their clinical experiences to find agreement on treatment of PANS and PANDAS symptoms. RESULTS Current guidelines result from consensus among the Consortium members. CONCLUSION While underlying infectious and inflammatory processes in PANS and PANDAS patients are treated, psychiatric and behavioral symptoms need simultaneous treatment to decrease suffering and improve adherence to therapeutic intervention. Psychological, behavioral, and psychopharmacologic interventions tailored to each child's presentation can provide symptom improvement and improve functioning during both the acute and chronic stages of illness. In general, typical evidence-based interventions are appropriate for the varied symptoms of PANS and PANDAS. Individual differences in expected response to psychotropic medication may require marked reduction of initial treatment dose. Antimicrobials and immunomodulatory therapies may be indicated, as discussed in Parts 2 and 3 of this guideline series.
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Affiliation(s)
| | - Tanya Murphy
- University of South Florida, St. Petersburg, Florida
| | | | | | - Kyle Williams
- Massachusetts General Hospital, Boston, Massachusetts
| | | | | | | | | | - Kiki Chang
- Stanford University, Stanford, California
| | - Josephine Elia
- Nemours, Alfred I duPont Hospital for Children, Wilmington, Delaware
| | - Susan Swedo
- National Institute of Mental Health, Bethesda, Maryland
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Kim HW, Kim E, Kim JH, Park J, Bahn GH, Lee YJ, Jhung K, Shin D. The Revised Korean Practice Parameter for the Treatment of Attention-Deficit Hyperactivity Disorder (III) - Pharmacological Treatment -. Soa Chongsonyon Chongsin Uihak 2017. [DOI: 10.5765/jkacap.2017.28.2.70] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Hyo-Won Kim
- Department of Psychiatry, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Eunjoo Kim
- Department of Psychiatry, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - Ji-Hoon Kim
- Department of Psychiatry, Pusan National University School of Medicine, Busan, Korea
| | - Jangho Park
- Department of Psychiatry, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Geon Ho Bahn
- Department of Psychiatry, Kyung Hee University School of Medicine, Seoul, Korea
| | - Yeon Jung Lee
- Department of Psychiatry, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Kyungun Jhung
- Department of Psychiatry, International St. Mary’s Hospital, Catholic Kwandong University, Incheon, Korea
| | - Dongwon Shin
- Department of Psychiatry, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Korea
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Ganos C, Martino D, Pringsheim T. Tics in the Pediatric Population: Pragmatic Management. Mov Disord Clin Pract 2017; 4:160-172. [PMID: 28451624 PMCID: PMC5396140 DOI: 10.1002/mdc3.12428] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 07/23/2016] [Accepted: 07/27/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Primary tic disorders, notably Tourette syndrome, are very common movement disorders in childhood. However, the management of such patients still poses great therapeutic challenges to medical professionals. METHODS Based on a synthesis of the available guidelines published in Europe, Canada, and the United States, coupled with more recent therapeutic developments, the authors provide a pragmatic guide to aid clinicians in deciding when and how to treat patients who have primary tic disorders. RESULTS After a systematic assessment of tics and common neuropsychiatric comorbidities (primarily attention-deficit hyperactivity disorder [ADHD] and obsessive-compulsive disorder [OCD]), the first step in treatment is a comprehensive psychoeducation of patients and families that addresses the protean phenomenology of tics and associated behaviors, coping mechanisms, prognosis, and treatment options. When more active intervention beyond watchful monitoring is indicated, hierarchical evaluation of treatment targets (i.e., tics vs. comorbid behavioral symptoms) is crucial. Behavioral treatments for tics are restricted to older children and are not readily available to all centers, mainly due to the paucity of well-trained therapists. Pharmacological treatments, such as antipsychotics for tics, stimulants and atomoxetine for ADHD, and α2A-agonists for children with tics plus ADHD, represent widely available and effective treatment options, but safety monitoring must be provided. Combined polypharmacological and behavioral/pharmacological approaches, as well as neuromodulation strategies, remain under-investigated in this population of patients. CONCLUSIONS The treatment of children with tics and Tourette syndrome is multifaceted. Multidisciplinary teams with expertise in neurology, psychiatry, psychology, and pediatrics may be helpful to address the complex needs of these children.
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Affiliation(s)
- Christos Ganos
- Department of NeurologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
- Sobell Department of Motor Neuroscience and Movement DisordersUniversity College London Institute of NeurologyUniversity College LondonLondonUnited Kingdom
| | - Davide Martino
- International Parkinson's Centre of ExcellenceKing's College and King's College HospitalDenmark Hill CampusLondonUnited Kingdom
- Queen Elizabeth Hospital, WoolwichLewisham and Greenwich National Health Service TrustLondonUnited Kingdom
| | - Tamara Pringsheim
- Department of Clinical NeurosciencesUniversity of CalgaryCalgaryAlbertaCanada
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Venables M, Ntzani E, Hsia Y, Gillies D. Alpha2 adrenergic agonists for attention deficit hyperactivity disorder (ADHD). Hippokratia 2017. [DOI: 10.1002/14651858.cd010016.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Michael Venables
- Child and Adolescent Mental Health Services; New Park House North Street Horsham Sussex UK RH12 1RJ
| | - Evangelia Ntzani
- University of Ioannina School of Medicine; Department of Hygiene and Epidemiology; 45 110 Ioannina Greece 45110
| | - Yingfen Hsia
- School of Pharmacy, University College London; Department of Practice and Policy; University of London l Level, BMA House Tavistock Square London UK WC1H 9JP
| | - Donna Gillies
- Western Sydney Local Health District - Mental Health; Cumberland Hospital Locked Bag 7118 Parramatta NSW Australia 2124
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Hollis C, Pennant M, Cuenca J, Glazebrook C, Kendall T, Whittington C, Stockton S, Larsson L, Bunton P, Dobson S, Groom M, Hedderly T, Heyman I, Jackson GM, Jackson S, Murphy T, Rickards H, Robertson M, Stern J. Clinical effectiveness and patient perspectives of different treatment strategies for tics in children and adolescents with Tourette syndrome: a systematic review and qualitative analysis. Health Technol Assess 2016; 20:1-450, vii-viii. [PMID: 26786936 DOI: 10.3310/hta20040] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Tourette syndrome (TS) is a neurodevelopmental condition characterised by chronic motor and vocal tics affecting up to 1% of school-age children and young people and is associated with significant distress and psychosocial impairment. OBJECTIVE To conduct a systematic review of the benefits and risks of pharmacological, behavioural and physical interventions for tics in children and young people with TS (part 1) and to explore the experience of treatment and services from the perspective of young people with TS and their parents (part 2). DATA SOURCES For the systematic reviews (parts 1 and 2), mainstream bibliographic databases, The Cochrane Library, education, social care and grey literature databases were searched using subject headings and text words for tic* and Tourette* from database inception to January 2013. REVIEW/RESEARCH METHODS For part 1, randomised controlled trials and controlled before-and-after studies of pharmacological, behavioural or physical interventions in children or young people (aged < 18 years) with TS or chronic tic disorder were included. Mixed studies and studies in adults were considered as supporting evidence. Risk of bias associated with each study was evaluated using the Cochrane tool. When there was sufficient data, random-effects meta-analysis was used to synthesize the evidence and the quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. For part 2, qualitative studies and survey literature conducted in populations of children/young people with TS or their carers or in health professionals with experience of treating TS were included in the qualitative review. Results were synthesized narratively. In addition, a national parent/carer survey was conducted via the Tourettes Action website. Participants included parents of children and young people with TS aged under 18 years. Participants (young people with TS aged 10-17 years) for the in-depth interviews were recruited via a national survey and specialist Tourettes clinics in the UK. RESULTS For part 1, 70 studies were included in the quantitative systematic review. The evidence suggested that for treating tics in children and young people with TS, antipsychotic drugs [standardised mean difference (SMD) -0.74, 95% confidence interval (CI) -1.08 to -0.41; n = 75] and noradrenergic agents [clonidine (Dixarit(®), Boehringer Ingelheim) and guanfacine: SMD -0.72, 95% CI -1.03 to -0.40; n = 164] are effective in the short term. There was little difference among antipsychotics in terms of benefits, but adverse effect profiles do differ. Habit reversal training (HRT)/comprehensive behavioural intervention for tics (CBIT) was also shown to be effective (SMD -0.64, 95% CI -0.99 to -0.29; n = 133). For part 2, 295 parents/carers of children and young people with TS contributed useable survey data. Forty young people with TS participated in in-depth interviews. Four studies were in the qualitative review. Key themes were difficulties in accessing specialist care and behavioural interventions, delay in diagnosis, importance of anxiety and emotional symptoms, lack of provision of information to schools and inadequate information regarding medication and adverse effects. LIMITATIONS The number and quality of clinical trials is low and this downgrades the strength of the evidence and conclusions. CONCLUSIONS Antipsychotics, noradrenergic agents and HRT/CBIT are effective in reducing tics in children and young people with TS. The balance of benefits and harms favours the most commonly used medications: risperidone (Risperdal(®), Janssen), clonidine and aripiprazole (Abilify(®), Otsuka). Larger and better-conducted trials addressing important clinical uncertainties are required. Further research is needed into widening access to behavioural interventions through use of technology including mobile applications ('apps') and video consultation. STUDY REGISTRATION This study is registered as PROSPERO CRD42012002059. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Chris Hollis
- Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, University of Nottingham, Nottingham, UK
| | - Mary Pennant
- National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK
| | - José Cuenca
- Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, University of Nottingham, Nottingham, UK
| | - Cris Glazebrook
- Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, University of Nottingham, Nottingham, UK
| | - Tim Kendall
- National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK
| | - Craig Whittington
- National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK
| | - Sarah Stockton
- National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK
| | - Linnéa Larsson
- National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK
| | - Penny Bunton
- School of Psychological Sciences, University of Manchester, Manchester, UK
| | - Suzanne Dobson
- Tourettes Action, The Meads Business Centre, Farnborough, Hampshire, UK
| | - Madeleine Groom
- Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, University of Nottingham, Nottingham, UK
| | - Tammy Hedderly
- Paediatric Neurology Department, Kings College Hospital NHS Foundation Trust, London, UK
| | - Isobel Heyman
- Department of Child and Adolescent Mental Health, Great Ormond Street Hospital for Children, London, UK
| | - Georgina M Jackson
- Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, University of Nottingham, Nottingham, UK
| | - Stephen Jackson
- School of Psychology, University of Nottingham, Nottingham, UK
| | - Tara Murphy
- Institute of Neurology, University College London, London, UK
| | | | - Mary Robertson
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Jeremy Stern
- Tourettes Action, The Meads Business Centre, Farnborough, Hampshire, UK
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Barnea M, Benaroya-Milshtein N, Gilboa-Sechtman E, Woods DW, Piacentini J, Fennig S, Apter A, Steinberg T. Subjective versus objective measures of tic severity in Tourette syndrome - The influence of environment. Psychiatry Res 2016; 242:204-209. [PMID: 27289326 DOI: 10.1016/j.psychres.2016.05.047] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 05/18/2016] [Accepted: 05/28/2016] [Indexed: 11/16/2022]
Abstract
The objective of this study was to examine the influence of environmental challenges on tic expression by subjective and objective measures. The study group consisted of 41 children aged 6-18 years (M=10.15, SD=2.73) with a primary diagnosis of Tourette syndrome. Subjective measures included the Functional Assessment Interview developed for this study and three standard validated instruments. The objective measure was a video-recording of the patients in five daily-life situations: watching television, doing homework, being alone, receiving attention when ticcing, and talking to a stranger. In addition, the effect of premonitory urges on assessment of tic expression was evaluated. The associations between the subjective and objective measures of tic expression were moderate to low. A significantly higher number of tics were observed in the television situation, and a significantly lower number in the alone situation, compared to the other situations. Higher levels of premonitory urge were associated with greater awareness of objectively measured tic expression. In conclusion, tic expression is significantly influenced by the environment. Subjective measures of tic expression may be misleading. These results have implications for refining the clinical assessment of tics, improving research methodology, and developing new therapeutic strategies.
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Affiliation(s)
- Meirav Barnea
- The Harry Freund Neuro-Psychiatric Clinic, Schneider's Children's Medical Center of Israel, Petach Tikva 49202, Israel; Bar-Ilan University, Ramat Gan 52900, Israel.
| | - Noa Benaroya-Milshtein
- The Harry Freund Neuro-Psychiatric Clinic, Schneider's Children's Medical Center of Israel, Petach Tikva 49202, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | | | | | - John Piacentini
- University of California - Los Angeles, Los Angeles CA 90095, USA
| | - Silvana Fennig
- The Harry Freund Neuro-Psychiatric Clinic, Schneider's Children's Medical Center of Israel, Petach Tikva 49202, Israel
| | - Alan Apter
- The Harry Freund Neuro-Psychiatric Clinic, Schneider's Children's Medical Center of Israel, Petach Tikva 49202, Israel
| | - Tamar Steinberg
- The Harry Freund Neuro-Psychiatric Clinic, Schneider's Children's Medical Center of Israel, Petach Tikva 49202, Israel
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Kovshoff H, Banaschewski T, Buitelaar JK, Carucci S, Coghill D, Danckaerts M, Dittmann RW, Falissard B, Grimshaw DG, Hollis C, Inglis S, Konrad K, Liddle E, McCarthy S, Nagy P, Thompson M, Wong IC, Zuddas A, Sonuga-Barke EJ. Reports of Perceived Adverse Events of Stimulant Medication on Cognition, Motivation, and Mood: Qualitative Investigation and the Generation of Items for the Medication and Cognition Rating Scale. J Child Adolesc Psychopharmacol 2016; 26:537-47. [PMID: 27007169 PMCID: PMC4991592 DOI: 10.1089/cap.2015.0218] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE There is no questionnaire to specifically monitor perceived adverse events of methylphenidate (MPH) on cognition, motivation, and mood. The current study therefore had two goals. First, to harvest accounts of such putative events from transcripts of interviews in samples enriched for such potential experiences. Second, to use the derived data to generate items for a new questionnaire that can be used for monitoring such events in medication trials or routine clinical care. METHODS Following a literature search aimed at identifying associations between MPH and cognition and/or motivation, a qualitative semistructured interview was designed to focus specifically on the domains of cognition (i.e., reasoning, depth/breadth of thinking, intellectual capacity, and creativity) and motivation (i.e., drive, effort, and attitudes toward rewards/incentives). Interviews were conducted with 45 participants drawn from the following four groups: (a) clinicians, child and adolescent psychiatrists, and pediatricians specializing in attention-deficit/hyperactivity disorder (ADHD) (n = 15); (2) teachers, with experience of teaching at least 10 medicated children with ADHD (n = 10); (3) parents of children with ADHD (n = 8) treated with MPH; and (4) adolescents/adults with ADHD (n = 12). Purposeful sampling was used to selectively recruit ADHD participants whose histories suggested a degree of vulnerability to MPH adverse events. Data were analyzed using a deductive approach to content analysis. RESULTS While we probed purposefully for cognitive and motivational adverse events, a third domain, related to mood, emerged from the reports. Therefore, three domains, each with a number of subdomains, were identified from the interview accounts: (i) Cognition (six subdomains; attention/concentration, changes in thinking, reduced creativity, sensory overload, memory, slower processing speed); (ii) motivation (four subdomains; loss of intrinsic motivation for goal-directed activities, external locus of control, lack of effort/engagement in daily tasks, increased focus on incentives); and (iii) mood (three subdomains; dampening of spontaneity/flat affect, mood dysregulation, increased anxiety/edginess). On the basis of these reports, 34 items were specified and incorporated into a prototype questionnaire, which was piloted and refined on the basis of field-testing. CONCLUSIONS Items were identified that capture potential/perceived cognitive, motivational, and mood-related adverse events of MPH. The items generated will allow us to further develop and psychometrically examine their prevalence, and the extent to which they are associated with medication adherence, treatment outcome, impairment, and other reported adverse events (e.g., loss of appetite/cardiovascular effects).
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Affiliation(s)
- Hanna Kovshoff
- Academic Unit of Psychology, University of Southampton, Southampton, United Kingdom
| | - Tobias Banaschewski
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Jan K. Buitelaar
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behavior, Department of Cognitive Neuroscience & Karakter Child and Adolescent Psychiatry University Centre, Nijmegen, the Netherlands
| | - Sara Carucci
- Child and Adolescent Neuropsychiatry Unit, Department of Biomedical Science, University of Cagliari,Italy
| | - David Coghill
- Division of Neuroscience, School of Medicine, University of Dundee, Dundee, United Kingdom
- Departments of Paediatrics and Psychiatry, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia
| | - Marina Danckaerts
- Department of Neurosciences, Research Group Psychiatry, KU Leuven, Belgium
| | - Ralf W. Dittmann
- Paediatric Psychopharmacology, Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Bruno Falissard
- INSERM U1178, University Paris-Sud, University Paris-Descartes, AP-HP, Paris, France
| | | | - Chris Hollis
- Institute of Mental Health, Faculty of Medicine and Health Sciences, University of Nottingham, United Kingdom
| | - Sarah Inglis
- Tayside Clinical Trials Unit, University of Dundee, Dundee, United Kingdom
| | - Kerstin Konrad
- Clinical Child Neuropsychology, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, University Hospital RWTH Aachen, Aachen, Germany
- Institute of Neuroscience & Medicine (INM3), Research Centre Juelich, Germany
| | - Elizabeth Liddle
- Institute of Mental Health, Faculty of Medicine and Health Sciences, University of Nottingham, United Kingdom
| | | | - Peter Nagy
- Vadaskert Child and Adolescent Psychiatric Hospital, Budapest, Hungary
| | - Margaret Thompson
- Academic Unit of Psychology, University of Southampton, Southampton, United Kingdom
| | - Ian C.K. Wong
- UCL School of Pharmacy, London, United Kingdom
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine University of Hong Kong, China
| | - Alessandro Zuddas
- Child and Adolescent Neuropsychiatry Unit, Department of Biomedical Science, University of Cagliari,Italy
| | - Edmund J.S. Sonuga-Barke
- Academic Unit of Psychology, University of Southampton, Southampton, United Kingdom
- Department of Experimental Clinical & Health Psychology, Ghent University, Ghent, Belgium
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Affiliation(s)
- Alexander K C Leung
- Department of Paediatrics, Alberta Children's Hospital, University of Calgary, #200, 233-16th Avenue North West, Calgary, Alberta T2M 0H5, Canada.
| | - Kam Lun Hon
- Department of Paediatrics, Chinese University of Hong Kong, 6/F, Clinical Sciences Building, Prince of Wales Hospital, Shatin, Hong Kong, China
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Otasowie J, Castells X, Ehimare UP, Smith CH. Tricyclic antidepressants for attention deficit hyperactivity disorder (ADHD) in children and adolescents. Cochrane Database Syst Rev 2014; 2014:CD006997. [PMID: 25238582 PMCID: PMC11236426 DOI: 10.1002/14651858.cd006997.pub2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Attention deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder of childhood onset, which may persist into adulthood. ADHD has a significant impact on a child's daily life, affecting relationships and academic performance. Its core symptoms include developmentally inappropriate levels of inattention, hyperactivity, and impulsive behaviour. Tricyclic antidepressants (TCAs) are sometimes used as second line of treatment in the reduction of ADHD symptoms in children and adolescents with ADHD. However, their efficacy is not yet known. OBJECTIVES To assess the efficacy of TCAs in the reduction of ADHD symptoms within the broad categories of hyperactivity, impulsivity, and inattentiveness in young people aged 6 to 18 years with established diagnoses of ADHD. SEARCH METHODS On 26 September 2013, we searched CENTRAL, Ovid MEDLINE, Embase, PsycINFO, CINAHL, seven other databases, and two trials registers. We also searched the reference lists of relevant articles, and contacted manufacturers and known experts in the field to determine if there were any ongoing trials or unpublished studies available. SELECTION CRITERIA Randomised controlled trials (RCTs), including both parallel group and cross-over study designs, of any dose of TCA compared with placebo or active medication in children or adolescents with ADHD, including those with comorbid conditions. DATA COLLECTION AND ANALYSIS Working in pairs, three review authors independently screened records, extracted data, and assessed trial quality. We calculated the standardised mean differences (SMD) for continuous data, the odds ratio (OR) for dichotomous data, and 95% confidence intervals (CIs) for both. We conducted the meta-analyses using a random-effects model throughout. We used the Cochrane 'Risk of bias' tool to assess the risk of bias of each included trial and the GRADE approach to assess the quality of the body evidence. MAIN RESULTS We included six RCTs with a total of 216 participants. Five of the six trials compared desipramine with placebo; the remaining trial compared nortriptyline with placebo. One trial compared desipramine with clonidine and placebo, and another compared two TCAs (desipramine and clomipramine) with methylphenidate and placebo. Of the six trials, one RCT primarily assessed the efficacy of TCA in children with ADHD and comorbid tic or Tourette disorder, and another one trial was in children with comorbid tic disorder. RCTs that met our inclusion criteria varied both in design and quality, and none were free of bias. The quality of the evidence was low to very low according to our GRADE assessments.TCA outperformed placebo regarding the proportions of patients achieving a predefined improvement of core ADHD symptom severity (OR 18.50, 95% CI 6.29 to 54.39, 3 trials, 125 participants, low quality evidence). In particular, there was evidence that desipramine improved the core symptoms of ADHD in children and adolescents as assessed by parents (SMD -1.42, 95% CI -1.99 to -0.85, 2 trials, 99 participants, low quality evidence), teachers (SMD -0.97, 95% CI -1.66 to -0.28, 2 trials, 89 participants, low quality evidence), and clinicians (OR 26.41, 95% CI 7.41 to 94.18, 2 trials, 103 participants, low quality evidence). Nortriptryline was also efficacious in improving the core symptoms of ADHD in children and adolescents as assessed by clinicians (OR 7.88, 95% CI 1.10 to 56.12). Desipramine and placebo were similar on "all-cause treatment discontinuation" (RD -0.10, 95% CI -0.25 to 0.04, 3 trials, 134 participants, very low quality evidence). Desipramine appeared more efficacious than clonidine in reducing ADHD symptoms as rated by parents (SMD -0.90, 95% CI -1.40 to -0.40, 1 trial, 68 participants, very low quality evidence) in participants with ADHD and comorbid tics or Tourette syndrome.Although this Cochrane Review did not identify serious adverse effects in patients taking TCAs, it did identify mild increases in diastolic blood pressure and pulse rates. Also, patients treated with desipramine had significantly higher rates of appetite suppression compared to placebo whilst nortriptyline resulted in weight gain. Other reported adverse effects included headache, confusion, sedation, tiredness, blurred vision, diaphoresis, dry mouth, abdominal discomfort, constipation, and urinary retention. AUTHORS' CONCLUSIONS Most evidence on TCAs relates to desipramine. Findings suggest that, in the short term, desipramine improves the core symptoms of ADHD, but its effect on the cardiovascular system remains an important clinical concern. Thus, evidence supporting the clinical use of desipramine for the treatment of children with ADHD is low.
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Affiliation(s)
- John Otasowie
- Child and Family Service, Worcestershire Health and Care NHS Trust, Aconbury North, Worcester, UK, WR5 1JG
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Buse J, Schoenefeld K, Münchau A, Roessner V. Neuromodulation in Tourette syndrome: Dopamine and beyond. Neurosci Biobehav Rev 2013; 37:1069-84. [DOI: 10.1016/j.neubiorev.2012.10.004] [Citation(s) in RCA: 136] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 09/28/2012] [Accepted: 10/08/2012] [Indexed: 01/11/2023]
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De Sousa A, Kalra G. Drug therapy of attention deficit hyperactivity disorder: current trends. Mens Sana Monogr 2012; 10:45-69. [PMID: 22654382 PMCID: PMC3353606 DOI: 10.4103/0973-1229.87261] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 10/15/2011] [Accepted: 10/17/2011] [Indexed: 11/04/2022] Open
Abstract
Attention deficit hyperactivity disorder is a developmental disorder with an age onset prior to 7 years. Children with ADHD have significantly lower ability to focus and sustain attention and also score higher on impulsivity and hyperactivity. Stimulants, such as methylphenidate, have remained the mainstay of ADHD treatment for decades with evidence supporting their use. However, recent years have seen emergence of newer drugs and drug delivery systems, like osmotic release oral systems and transdermal patches, to mention a few. The use of nonstimulant drugs like atomoxetine and various other drugs, such as α-agonists, and a few antidepressants, being used in an off-label manner, have added to the pharmacotherapy of ADHD. This review discusses current trends in drug therapy of ADHD and highlights the promise pharmacogenomics may hold in the future.
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Affiliation(s)
- Avinash De Sousa
- Consultant Psychiatrist & Founder Trustee, Desousa Foundation, Carmel, 18, St. Francis Avenue, Off SV Road, Santacruz West, Mumbai-400 054, Maharashthra, India
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The use of medication against attention deficit/hyperactivity disorder in Denmark: a drug use study from a patient perspective. Eur J Clin Pharmacol 2012; 69:589-98. [DOI: 10.1007/s00228-012-1344-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 06/21/2012] [Indexed: 11/27/2022]
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Bloch MH. Misplaced Fear? FDA Contraindication to Psychostimulant Use in Children with Tics. EVIDENCE-BASED CHILD HEALTH : A COCHRANE REVIEW JOURNAL 2012; 7:1231-1234. [PMID: 25152702 PMCID: PMC4140657 DOI: 10.1002/ebch.1862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Michael H Bloch
- Child Study Center and Department of Psychiatry of Yale University
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Kallapiran GK, Mammen P, Tharyan P, Russell P. Atomoxetine for Attention Deficit Hyperactivity Disorder (ADHD) in children and adolescents. Hippokratia 2012. [DOI: 10.1002/14651858.cd009804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- G Kannan Kallapiran
- Children's Hospital Westmead; Psychological Medicine; Cnr Hawkesbury Rd & Hainsworth Street Westmead NSW Australia 2145
| | - Priya Mammen
- Christian Medical College; Child & Adolescent Psychiatry; Vellore TN India
| | - Prathap Tharyan
- Christian Medical College; South Asian Cochrane Network & Centre, Prof. BV Moses & ICMR Advanced Centre for Research & Training in Evidence Informed Health Care; Carman Block II Floor CMC Campus, Bagayam Vellore Tamil Nadu India 632002
| | - Paul Russell
- Christian Medical College; Child & Adolescent Psychiatry; Vellore TN India
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Storebø OJ, Skoog M, Damm D, Thomsen PH, Simonsen E, Gluud C. Social skills training for Attention Deficit Hyperactivity Disorder (ADHD) in children aged 5 to 18 years. Cochrane Database Syst Rev 2011:CD008223. [PMID: 22161422 DOI: 10.1002/14651858.cd008223.pub2] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Attention Deficit Hyperactivity Disorder (ADHD) in children is associated with hyperactivity and impulsitivity, attention problems, and difficulties with social interactions. Pharmacological treatment may alleviate symptoms of ADHD but seldom solves difficulties with social interactions. Social skills training may benefit ADHD children in their social interactions. We examined the effects of social skills training on children's social competences, general behaviour, ADHD symptoms, and performance in school. OBJECTIVES To assess the effects of social skills training in children and adolescents with ADHD. SEARCH METHODS We searched the following electronic databases: CENTRAL (2011, Issue1), MEDLINE (1948 to March 2011), EMBASE (1980 to March 2011), ERIC (1966 to March 2011 ), AMED (1985 to June 2011), PsycINFO (1806 to March 2011), CINAHL (1980 to March 2011), and Sociological Abstracts (1952 to March 2011). We also searched the metaRegister of Controlled Trials on 15 October 2010. We did not apply any language or date restrictions to the searches. We searched online conference abstracts and contacted 176 experts in the field for possible information about unpublished or ongoing RCTs. SELECTION CRITERIA Randomised trials investigating social skills training for children with ADHD as a stand alone treatment or as an adjunct to pharmacological treatment. DATA COLLECTION AND ANALYSIS We conducted the review according to the Cochrane Handbook for Systematic Reviews of Intervention. Two authors (OJS, MS) extracted data independently using an appropriate data collection form. We performed the analyses using Review Manager 5 software. MAIN RESULTS We included 11 randomised trials described in 26 records (all full text articles) in the review. The trials included a total of 747 participants. All participants were between five and 12 years of age. No trials assessed adolescents. In 10 of the trials the participants suffered from different comorbidities.The duration of the interventions ranged from eight to 10 weeks (eight trials) up to two years. The types of social skills interventions were named social skills training, cognitive behavioural intervention, multimodal behavioural/psychosocial therapy, behavioural therapy/treatment, behavioural and social skills treatment, and psychosocial treatment. The content of the social skills interventions were comparable and based on a cognitive behavioural model. Most of the trials compared child social skills training and parent training plus medication versus medication alone. Some of the experimental interventions also included teacher consultations.More than half of the trials were at high risk of bias regarding generation of the allocation sequence and allocation concealment. No trial reported blinding of participants and personnel and most of the trials had no reports regarding differences between groups in collateral medication for comorbid disorders. Overall, the trials had high risk of bias due to systematic errors. Even so, as recommended by the Cochrane Handbook of Systematic Reviews of Interventions, we used all eligible trials in the meta-analysis, but the results are downgraded to low quality evidence.There were no statistically significant treatment effects either on social skills competences (positive value = better for the intervention group) (SMD 0.16; 95% CI -0.04 to 0.36; 5 trials, n = 392), on the teacher-rated general behaviour (negative value = better for the intervention group) (SMD 0.00; 95% CI -0.21 to 0.21; 3 trials, n = 358), or on the ADHD symptoms (negative value = better for the intervention group) (SMD -0.02; 95% CI -0.19 to 0.16; 6 trials, n = 515).No serious or non-serious adverse events were reported. AUTHORS' CONCLUSIONS The review suggests that there is little evidence to support or refute social skills training for adolescents with ADHD. There is need for more trials, with low risk of bias and with a sufficient number of participants, investigating the efficacy of social skills training versus no training for both children and adolescents.
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Affiliation(s)
- Ole Jakob Storebø
- Child Psychiatric Clinic, Psychiatric Department, Region Zealand, Birkevaenget 3, Holbaek, Denmark, 4300
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Comparative efficacy and acceptability of methylphenidate and atomoxetine in treatment of attention deficit hyperactivity disorder in children and adolescents: a meta-analysis. BMC Psychiatry 2011; 11:176. [PMID: 22074258 PMCID: PMC3229459 DOI: 10.1186/1471-244x-11-176] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2011] [Accepted: 11/10/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Psychostimulants and non stimulants are effective in the treatment of ADHD. Efficacy of both methylphenidate and atomoxetine has been established in placebo controlled trials. Direct comparison of efficacy is now possible due to availability of results from several head-to-head trials of these two medications. METHODS All published, randomized, open label or double blind trials, comparing efficacy of methylphenidate with atomoxetine, in treatment of ADHD in children, diagnosed using DSM-IV™ criteria were included. The outcome studied was ADHDRS-IVParent:Inv score. The standardized mean difference (SMD) was used as a measure of effect size. RESULTS Nine randomized trials comparing methylphenidate and atomoxetine, with a total of 2762 participants were included. Meta-analysis did not find a significant difference in efficacy between methylphenidate and atomoxetine (SMD=0.09, 95% CI -0.08-0.26) (Z=1.06, p=0.29). Synthesis of data from eight trials found no significant difference in response rates (RR=0.93 95% CI 0.76-1.14, p=0.49). Sub group analysis showed a significant standardized mean difference favouring OROS methylphenidate (SMD=0.32, 95% CI 0.12-0.53 (Z=3.05, p<0.002). Immediate release methylphenidate was not superior to atomoxetine (SMD=-0.04, 95% CI -0.19-0.12) (Z=0.46, p=0.64). Excluding open label trials did not significantly alter the effect size (SMD=0.08, 95% CI -0.04-0.21) (Z=1.27, p=0.20). All-cause discontinuation was used as a measure of acceptability. There was no significant difference in all cause discontinuation between atomoxetine and methylphenidate (RR 1.22, 95% CI 0.87-1.71). There was significant heterogeneity among the studies (p=0.002, I2=67%). Subgroup analysis demonstrated the heterogeneity to be due to the open label trials (p=0.001, I2=81%). CONCLUSIONS In general atomoxetine and methylphenidate have comparable efficacy and equal acceptability in treatment of ADHD in children and adolescents. However OROS methylphenidate is more effective than atomoxetine and may be considered as first line treatment in treatment of ADHD in children and adolescents.
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