Effects of methylphenidate and bupropion on DHEA-S and cortisol plasma levels in attention-deficit hyperactivity disorder

Changes in Cortisol and in Oxidative/Nitrosative Stress Indicators after ADHD Treatment

Although ADHD is one of the most prevalent diseases during childhood, we still do not know its precise origin; oxidative/nitrosative stress and the hypothalamic-pituitary-adrenal axis are suggested contributors. Methylphenidate, among others, is the main drug used in ADHD patients, but its effects on relevant markers and structures remain unclear. This study, involving 59 patients diagnosed with ADHD according to DSM-5 criteria, aimed to assess changes in cortisol levels (using cortisol awakening response, CAR) and oxidative/nitrosative status with the treatment. Blood samples before and 3 months after treatment with methylphenidate were used to measure oxidative and inflammatory markers, as well as the endogenous antioxidant activity, while saliva samples tracked cortisol awakening response (CAR). The results showed a treatment-related improvement in the redox profile, with the reduction in advanced oxidation protein products (AOPP), lipid peroxidation (LPO), and nitrite plus nitrate (NOx) levels, and the increase in the enzymatic activities of glutathione reductase (GRd) and catalase (CAT). Moreover, the area under the curve (AUC) of CAR increased significantly, indicating increased reactivity of the HPA axis. These results support, for the first time, the involvement of the endogenous antioxidant system in the pathophysiology of ADHD.

Temperament Dimensions and Awakening Cortisol Levels in Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

To investigate whether temperament dimensions, Effortful Control (EC), Surgency-Extraversion (SE), and Negative Affectivity (NA), are associated with attention-deficit/hyperactivity disorder (ADHD) and how they relate to awakening cortisol levels, as a proxy measure of peripheral arousal.

METHODS

Parent-rated temperament and saliva samples were collected from 55 children with ADHD and 65 age-matched controls.

RESULTS

Compared to controls, youths with ADHD showed lower EC, higher NA, and lower awakening cortisol levels but did not differ in SE. Similar findings emerged in dimensional analyses linking temperament traits to inattention and hyperactivity-impulsivity symptoms. The results remained unchanged when controlling for the presence of co-occurring opposition-defiance and anxiety traits, as well as medication status. Temperament dimensions were not associated with cortisol levels.

CONCLUSIONS

Poor temperamental emotional and cognitive self-regulation showed significant associations with ADHD but did not appear to be linked to the under-arousal typically seen in ADHD.

Animal models of attention-deficit hyperactivity disorder (ADHD)

Attention-deficit hyperactivity disorder (ADHD) is a heterogeneous neuropsychiatric disorder characterized by three primary symptoms hyperactivity, attention deficit, and impulsiveness, observed in both children and adults. In childhood, this disorder is more common in boys than in girls, and at least 75% will continue to suffer from the disorder until adulthood. Individuals with ADHD generally have poor academic, occupational, and social functioning resulting from developmentally inappropriate levels of hyperactivity and impulsivity, as well as impaired ability to maintain attention on motivationally relevant tasks. Very few drugs available in clinical practice altogether abolish the symptoms of ADHD, therefore, to find new drugs and target it is essential to understand the neuropathological, neurochemical, and genetic alterations that lead to the progression of ADHD. With this contrast, an animal study is the best approach because animal models provide relatively fast invasive manipulation, rigorous hypothesis testing, as well as it provides a better angle to understand the pathological mechanisms involved in disease progression. Moreover, animal models, especially for ADHD, serve with good predictive validity would allow the assessment and development of new therapeutic interventions, with this aim, the present review collect the various animal models on a single platform so that the research can select an appropriate model to pursue his study.

Effect of one-month treatment with methylphenidate on salivary cortisol level of attention deficit hyperactivity disorder children

Background

Attention deficit hyperactivity disorder (ADHD) is one of the most common neuropsychological disorders that affects children, adolescents, and adults. Dysfunction of the hypothalamic-pituitary-adrenal axis (HPA) has been implicated in its pathophysiology. So, this study aimed to compare the salivary cortisol level between ADHD children and healthy children. It also compared the salivary cortisol level of ADHD children before treatment and 1 month after treatment with methylphenidate.

Results

This study showed that there was a statistically significant decrease in salivary cortisol level of the ADHD group, specifically hyperactive/impulsive subtype compared to the control group. Furthermore, it showed a statistically significant increase of salivary cortisol level after treatment compared to before treatment in the ADHD group.

Conclusions

HPA axis dysfunction may be related to the pathophysiology of ADHD, specifically hyperactive/impulsive subtype. Methylphenidate positively affects the HPA axis of ADHD children.

Psychotropic medication effects on cortisol: Implications for research and mechanisms of drug action

Stress and the hypothalamic-pituitary-adrenal (HPA) axis have been implicated in the etiology of a range psychiatric disorders; abnormalities in cortisol secretion are well documented in mood, anxiety, and psychotic disorders. There is, however, evidence that psychotropic medications affect HPA function, and are often a confound in research on the relation of cortisol secretion with psychiatric symptoms and syndromes. Psychotropic effects are particularly problematic in longitudinal research on individuals at clinical high risk (CHR) for serious mental illness, because they have the potential to obscure neurobiological mechanisms involved in crossing the threshold from CHR states to clinical disorders. This paper reviews the research literature on the relation of cortisol secretion with the three major classes of psychotropic medication that are most often prescribed; antipsychotics, antidepressants, and stimulants. The studies included in this review are those that measured both baseline and post-treatment cortisol. Taken together, most studies of antidepressants find that they are associated with a reduction in both basal and post-dexamethasone-CRH (DEX/CRH) cortisol, although some report no change. Similarly, antipsychotics, both typical and atypical, are found to reduce basal and DEX/CRH cortisol levels in most studies. Psychostimulant medications, in contrast, are associated with an increase in basal cortisol levels or no change. Effects of psychotropics on the cortisol awakening response (CAR) are less consistent. Implications of these effects for clinical research, especially studies of CHR populations, are discussed. Limitations of the research, due to variations in sample demographic and methodologic factors, are noted, and directions for future research are proposed.

Mullerian inhibiting substance, sex hormone binding globulin and sex hormone levels in stimulant-naïve, first-diagnosed prepubertal boys with attention-deficit/hyperactivity disorder: comparison with matched healthy controls as well as before and after oros-methylpenidate treatment

Objectives: Attention-Deficit/Hyperactivity Disorder (ADHD) is a complex neurodevelopmental disorder with strong male predominance. Since Müllerian Inhibiting Substance (MIS) produces sex-linked bias in animal studies, we aimed to investigate the role of MIS, Sex Hormone Binding Globulin (SHBG) and sex hormone levels in boys with ADHD.Methods: We compared prepubertal, psychostimulant-naïve boys with ADHD with age-matched healthy control boys (HCs). Patients were re-evaluated after 30 days of methylphenidate treatment assessing ADHD severity, and serum MIS, testosterone, estradiol, and albumin concentrations.Results: Compared to 30 HCs, with ADHD (n = 49, age = 6.9 ± 0.2 years) had lower SHBG (p = .014), and higher free testosterone (p = 0.006) and bioavailable testosterone (p = .002) percentages. Methylphenidate improved ADHD measures (all p < .0001) and abnormal baseline hormonal levels, increasing SHBG levels (p = .024), and lowering free (p = .001) and bioavailable testosterone (p = .016) percentages so that only free testosterone percentages remained higher versus HCs post-treatment (p = .02).Conclusions: Compared to age- and sex-matched HCs, prepubertal, stimulant-naïve boys with ADHD had significantly lower SHBG and higher free and bioavailable testosterone percentages, suggesting a possible contribution of sex hormones to ADHD. Osmotic-release oral system methylphenidate treatment for 30 days significantly improved ADHD symptoms and abnormal sex hormone levels, normalizing SHBG and bioavailable testosterone percentages that were similar to HCs while free testosterone remained elevated versus HCs.Key pointsCompare to healthy matched controls prepubertal stimulant-naïve boys with ADHD had significantly lower SHBG and higher free and bioavailable testosterone percentages, suggesting a possible effect on sex hormones to ADHD.After 30-day methylphenidate treatment, ADHD symptoms significantly improved, and SHBG and bioavailable testosterone percentages normalized which were similar to HCs, while free testosterone remained elevated versus HCs.We found a negative relationship between MIS levels and hyperactivity scores in ADHD boys. This finding suggests that MIS may contribute to hyperactivity symptoms, either directly by affecting behavior or indirectly by affecting sex hormone levels.

Dehydroepiandrosterone sulfate, free testosterone, and sex hormone-binding globulin on susceptibility to attention-deficit/hyperactivity disorder

The neuroendocrine system may affect the pathophysiology of gender differences in attention deficit/hyperactivity disorder (ADHD). This study examines whether the relationships among dehydroepiandrosterone sulfate (DHEA-S), free testosterone, or sex hormone-binding globulin (SHBG) and ADHD presentations exhibit gender differences. A total of 113 boys and 35 girls with ADHD (all drug naïve) and 46 and 26 healthy control boys and girls, respectively, were recruited. Blood samples were obtained to measure the serum levels of DHEA-S, free testosterone, and SHBG in each child. The Swanson, Nolan, and Pelham Scale for ADHD Version IV (SNAP-IV) was used to evaluate behavioral symptoms and the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) and the Conners' Continuous Performance Test (CPT) were utilized to assess neurocognitive functions. Patients with ADHD had lower DHEA-S levels than male and female healthy control subjects, and no significant differences were observed in free testosterone and SHBG levels between the patients and the controls. DHEA-S levels were negatively correlated with children's impulsivity performance in the CPT. SHBG levels were negatively correlated with ADHD behavior symptoms among boys. Free testosterone levels were not significantly correlated with either ADHD clinical symptoms or neuropsychological functions. We propose that DHEA-S serves as a potential biomarker of ADHD and is consistently involved in the pathogenesis of ADHD in both boys and girls. SHBG may be involved in behaviors associated with ADHD in boys. Additional studies with basic scientific measures are warranted to elucidate the relationship between androgen hormones and clinical presentations of ADHD.

Increased cortisol awakening response after completing the summer treatment program in children with ADHD

OBJECTIVE

Little is known about the cortisol awakening response (CAR) in children with attention deficit hyperactivity disorder (ADHD). Here, we examined the CAR in children with ADHD and their mothers before, immediately after, and 4months after an intensive summer treatment program (STP).

METHODS

Participants were 37 children aged 7-12years who completed the STP in 2009 and 2010, and their mothers. Daily saliva samples for cortisol measurement were collected twice daily at awakening and 30min afterwards at pre-STP, post-STP, and during a follow-up measurement period. ADHD symptom scores were evaluated by parents, and participants completed the Kid-KINDL^R QOL questionnaire.

RESULTS

CAR was low in children with ADHD before the STP, and increased to the control range 4months after STP. Maternal CAR also tended to increase after STP. Changes in the CAR in children tended to correlate with an improved ADHD inattention scores (p=0.091), physical health (p=0.070), and school life subscales scores in the Kid-KINDL^R (p=0.079).

CONCLUSION

We demonstrated that STP improved the behavior and QOL of children with ADHD. Our results indicate that STP could lead to improvements in HPA axis function, as reflected by increased CAR after STP.

Polymorphisms of STS gene and SULT2A1 gene and neurosteroid levels in Han Chinese boys with attention-deficit/hyperactivity disorder: an exploratory investigation

This study examined the relationships among polymorphisms of the STS gene and SULT2A1 gene, dehydroepiandrosterone (DHEA) and its sulfated form (DHEA-S), and characteristics of attention-deficit/hyperactivity disorder (ADHD). We used cheek swabs to obtain the genomic DNA of 200 ADHD male probands (mean age: 8.7 years), 192 patients’ mothers and 157 patients’ fathers. Three SNPs in the STS gene (rs6639786, rs2270112, and rs17268988) and one SNP in the SULT2A1 gene (rs182420) were genotyped. Saliva samples were collected from the ADHD patients to analyze DHEA and DHEA-S levels. The behavioral symptoms were evaluated with the Swanson, Nolan, and Pelham, and Version IV Scale for ADHD (SNAP-IV), and the neuropsychological function was assessed using the Conners’ Continuous Performance Tests (CPT). We found the C allele of rs2270112 within the STS gene to be over-transmitted in males with ADHD. Polymorphisms of rs182420 within the SULT2A1 gene were not associated with ADHD. In addition, the C allele carriers of rs2270112 demonstrated significantly higher DHEA-S levels than the G allele carriers. Levels of DHEA were positively correlated with attention as measured by the CPT. These findings support a potential role in the underlying biological pathogenesis of ADHD with regard to STS polymorphisms and neurosteroid levels.

Cortisol and DHEA in development and psychopathology

Dehydroepiandrosterone (DHEA) and cortisol are the most abundant hormones of the human fetal and adult adrenals released as end products of a tightly coordinated endocrine response to stress. Together, they mediate short- and long-term stress responses and enable physiological and behavioral adjustments necessary for maintaining homeostasis. Detrimental effects of chronic or repeated elevations in cortisol on behavioral and emotional health are well documented. Evidence for actions of DHEA that offset or oppose those of cortisol has stimulated interest in examining their levels as a ratio, as an alternate index of adrenocortical activity and the net effects of cortisol. Such research necessitates a thorough understanding of the co-actions of these hormones on physiological functioning and in association with developmental outcomes. This review addresses the state of the science in understanding the role of DHEA, cortisol, and their ratio in typical development and developmental psychopathology. A rationale for studying DHEA and cortisol in concert is supported by physiological data on the coordinated synthesis and release of these hormones in the adrenal and by their opposing physiological actions. We then present evidence that researching cortisol and DHEA necessitates a developmental perspective. Age-related changes in DHEA and cortisol are described from the perinatal period through adolescence, along with observed associations of these hormones with developmental psychopathology. Along the way, we identify several major knowledge gaps in the role of DHEA in modulating cortisol in typical development and developmental psychopathology with implications for future research.

Does Methylphenidate Reduce Testosterone Levels in Humans? A Prospective Study in Children with Attention-Deficit/Hyperactivity Disorder

Background

Animal studies and case reports have suggested that methylphenidate exerts adverse effects on gonadal hormones. This study aimed to determine whether methylphenidate alters testosterone levels in children with attention-deficit/hyperactivity disorder through comparison of those with or without methylphenidate treatment.

Methods

This 4-week, nonrandomized, prospective study conducted in Taiwan included 203 attention-deficit/hyperactivity disorder patients with a mean age of 8.7 years (boys: 75.8%). After the initial recruitment, 137 received daily methylphenidate treatment (medicated group) and 66 were assessed through naturalistic observation (nonmedicated group). The saliva samples of attention-deficit/hyperactivity disorder patients were used to quantify testosterone levels at baseline and the endpoint by using the chemiluminescence immunoassay. At the 4th week, 86 patients in the medicated group and 46 patients in the nonmedicated group were eligible for statistical analyses.

Results

During the study period, salivary testosterone levels did not significantly change in the medicated group (P=.389) or in the nonmedicated group (P=.488). After correction for the potential confounding effects of age and sex, salivary testosterone levels still remained unchanged in the medicated and nonmedicated groups during the 4-week follow-up. In the medicated group, changes in salivary testosterone levels over 4 weeks were not significantly correlated with the methylphenidate daily dose (mean daily dose: 18.1 mg).

Conclusions

Findings suggest that short-term treatment with methylphenidate at usual doses does not significantly alter salivary testosterone levels in attention-deficit/hyperactivity disorder patients. Future studies should clarify whether long-term methylphenidate treatment disrupts testosterone production as well as the function of the reproductive system.

The Trend in Morning Levels of Salivary Cortisol in Children With ADHD During 6 Months of Methylphenidate Treatment

OBJECTIVE

To determine the trend in cortisol levels in children with ADHD treated with methylphenidate (MPH) and nontreated healthy controls over a 6-month period.

METHOD

The morning salivary cortisol levels of 50 patients with ADHD (40 boys and 10 girls, mean age = 7.6 years) and 50 age- and gender-matched healthy controls were measured at baseline and at 1, 3, and 6 months from baseline. The neuropsychological performance of the ADHD patients was measured via administration of the Continuous Performance Test.

RESULTS

The cortisol levels of ADHD patients increased significantly after 1 month of MPH treatment before decreasing to an intermediate level, but were significantly positively correlated with neuropsychological performance throughout the 6-month treatment period. The cortisol levels of the controls did not change significantly over the 6-month period.

CONCLUSION

MPH administration appears to positively influence the functioning of the hypothalamic-pituitary-adrenal axis in ADHD patients.

Dysregulation of the cortisol diurnal rhythm following prenatal alcohol exposure and early life adversity

The hypothalamic-pituitary-adrenal (HPA) axis is impacted by a multitude of pre- and postnatal factors. Developmental programming of HPA axis function by prenatal alcohol exposure (PAE) has been demonstrated in animal models and in human infants, but remains understudied in older children and adolescents. Moreover, early life adversity (ELA), which occurs at higher rates in children with PAE than in non-exposed children, may also play a role in programming the stress response system. In a cohort of children and adolescents with PAE and ELA (PAE + ELA), we evaluated HPA function through assessment of diurnal cortisol activity compared to that in typically developing controls, as well as the associations among specific ELAs, adverse outcomes, protective factors, and diurnal cortisol. Morning and evening saliva samples were taken under basal conditions from 42 children and adolescents (5-18 years) with PAE + ELA and 43 typically developing controls. High rates of ELA were shown among children with PAE, and significantly higher evening cortisol levels and a flatter diurnal slope were observed in children with PAE + ELA, compared to controls. Medication use in the PAE + ELA group was associated with lower morning cortisol levels, which were comparable to controls. Complex associations were found among diurnal cortisol patterns in the PAE + ELA group and a number of ELAs and later adverse outcomes, whereas protective factors were associated with more typical diurnal rhythms. These results complement findings from research on human infants and animal models showing dysregulated HPA function following PAE, lending weight to the suggestion that PAE and ELA may interact to sensitize the developing HPA axis. The presence of protective factors may buffer altered cortisol regulation, underscoring the importance of early assessment and interventions for children with FASD, and in particular, for the many children with FASD who also have ELA.

Genetic and Environmental Contributions to Covariation Between DHEA and Testosterone in Adolescent Twins

Although several studies have shown that pubertal tempo and timing are shaped by genetic and environmental factors, few studies consider to what extent endocrine triggers of puberty are shaped by genetic and environmental factors. Doing so moves the field from examining correlated developmentally-sensitive biomarkers toward understanding what drives those associations. Two puberty related hormones, dehydroepiandrosterone and testosterone, were assayed from salivary samples in 118 MZ (62 % female), 111 same sex DZ (46 % female) and 103 opposite-sex DZ twin pairs, aged 12-16 years (M = 13.1, SD = 1.3). Pubertal status was assessed with a composite of mother- and self-reports. We used biometric models to estimate the genetic and environmental influences on the variance and covariance in testosterone and DHEA, with and without controlling for their association with puberty, and to test for sex differences. In males, the variance in testosterone and pubertal status was due to shared and non-shared environmental factors; variation in DHEA was due to genetic and non-shared environmental factors. In females, variance in testosterone was due to genetic and non-shared environmental factors; genetic, shared, and non-shared environmental factors contributed equally to variation in DHEA. In males, the testosterone-DHEA covariance was primarily due to shared environmental factors that overlapped with puberty as well as shared and non-shared environmental covariation specific to testosterone and DHEA. In females, the testosterone-DHEA covariance was due to genetic factors overlapping with pubertal status, and shared and non-shared environmental covariation specific to testosterone and DHEA.

Sex differences in attention Deficit Hyperactivity Disorder: candidate genetic and endocrine mechanisms

Attention Deficit Hyperactivity Disorder (ADHD) is a developmental condition characterised by severe inattention, pathological impulsivity and hyperactivity; it is relatively common affecting up to 6% of children, and is associated with a risk of long-term adverse educational and social consequences. Males are considerably more likely to be diagnosed with ADHD than females; the course of the disorder and its associated co-morbidities also appear to be sensitive to sex. Here, I discuss fundamental biological (genetic and endocrine) mechanisms that have been shown to, or could theoretically, contribute towards these sexually dimorphic phenomena. Greater understanding of how and why the sexes differ with respect to ADHD vulnerability should allow us to identify and characterise novel protective and risk factors for the disorder, and should ultimately facilitate improved diagnosis, prognosis and treatment.

Salivary neurosteroid levels and behavioural profiles of children with attention-deficit/hyperactivity disorder during six months of methylphenidate treatment

OBJECTIVE

This prospective study aimed to investigate the relationships between salivary levels of neurosteroids, including dehydroepiandrosterone (DHEA), cortisol, and DHEA/cortisol ratios, and behavioral symptoms in patients with attention-deficit/hyperactivity disorder (ADHD) during treatment with methylphenidate (MPH).

METHODS

Fifty-eight ADHD patients (48 boys and 10 girls) were included in the study initially. Forty patients (mean age: 7.77±1.64 years; 32 boys and 8 girls) who completed the study received treatment with oral MPH with a dose range of 5-15 mg/day (mean dose: 12.47±7.74 mg/day.) for 6 months at the discretion of the psychiatrist. DHEA and cortisol levels were determined from saliva samples collected at 0800 h at baseline and 6 months from baseline. ADHD symptoms were evaluated with the Child Behavior Checklist (CBCL).

RESULTS

Salivary DHEA levels (mean difference=9.05 pg/mL, p=0.027) and DHEA/cortisol ratios (mean difference=32.42, p=0.007) in ADHD patients were significantly increased, but the cortisol levels did not change significantly. During a 6 month follow-up, all behavioral problems assessed using the CBCL improved significantly. Changes in salivary DHEA levels were positively correlated with changes in salivary cortisol levels (r=0.44, p=0.004); however, changes in salivary levels of DHEA, cortisol, and the DHEA/cortisol ratio were not significantly correlated with change in any subscales of the CBCL. Mean doses of MPH were not significantly correlated with changes in neurosteroid levels and behavioral symptoms.

CONCLUSIONS

These findings provide evidence that MPH administration might affect DHEA levels and DHEA/cortisol ratios. Whether levels of neurosteroids are directly associated with brain function or behavioral problems in ADHD patients warrants further investigation.

Effects of stimulants and atomoxetine on cortisol levels in children with ADHD

Children with attention deficit hyperactivity disorder (ADHD) have lower diurnal cortisol levels than non-ADHD comparison subjects. Aiming at elucidating the effects of medications used to treat ADHD, we investigated saliva cortisol in children with ADHD: 20 without medication, 147 on methylphenidate, and 21 on atomoxetine. The only significant finding was that children on atomoxetine had higher cortisol levels at bedtime than unmedicated children.

Transgenic mouse models for ADHD

Attention-deficit hyperactivity disorder (ADHD) is a developmental disorder characterized by symptoms of inattention, impulsivity and hyperactivity that adversely affect many aspects of life. Whereas the etiology of ADHD remains unknown, growing evidence indicates a genetic involvement in the development of this disorder. The brain circuits associated with ADHD are rich in monoamines, which are involved in the mechanism of action of psychostimulants and other medications used to treat this disorder. Dopamine (DA) is believed to play a major role in ADHD but other neurotransmitters are certainly also involved. Genetically modified mice have become an indispensable tool used to analyze the contribution of genetic factors in the pathogenesis of human disorders. Although rodent models cannot fully recapitulate complex human psychiatric disorders such as ADHD, transgenic mice offer an opportunity to directly investigate in vivo the specific roles of novel candidate genes identified in ADHD patients. Several knock-out and transgenic mouse models have been proposed as ADHD models, mostly based on targeting genes involved in DA transmission, including the gene encoding the dopamine transporter (DAT1). These mutant models provided an opportunity to evaluate the contribution of dopamine-related processes to brain pathology, to dissect the neuronal circuitry and molecular mechanisms involved in the antihyperkinetic action of psychostimulants and to evaluate novel treatments for ADHD. New transgenic models mouse models targeting other genes have recently been proposed for ADHD. Here, we discuss the recent advances and pitfalls in modeling ADHD endophenotypes in genetically altered animals.

Cortisol levels in children with attention-deficit/hyperactivity disorder

Regulation of the Hypothalamus-Pituitary-Adrenal axis (HPA-axis) and its end product cortisol differs among persons with certain psychiatric disorders when compared with controls. Some reports concern Attention-Deficit/Hyperactivity Disorder (ADHD) but findings are inconclusive. In this study we collected four saliva samples during a regular weekday in children, 6-17 years old, with ADHD (n = 201) and non-affected comparisons (n = 221). Saliva cortisol was measured with radioimmunoassay technique. Clinical data were collected for diagnostic information. Subtypes and severity of symptoms were determined using parental rating scales. Children with ADHD had lower saliva cortisol levels than comparisons at waking up Median = 9.1 versus 12.7 nmol/L (p < .001), 30 min later Median = 15.8 versus 20.1 nmol/L (p < .001) and before going to bed Median = 0.8 versus 1.0 nmol/L (p = .015). No difference was found for the afternoon sample. When the study group was split into three different age groups similar results were found only for children above 10 years of age. Subtype of ADHD or co-occurring symptoms did not affect the cortisol levels. Degree of severity of ADHD symptoms was not associated with cortisol levels in the study group, other than a weak negative correlation between the afternoon sample and hyperactivity symptoms. The low cortisol levels in children with ADHD may indicate a dysregulation of the HPA-axis, for instance a down-regulation or a phase delay of the diurnal curve. The low levels may be related to the under-arousal possibly underlying several of the core symptoms of ADHD.

Biomarkers and attention-deficit/hyperactivity disorder: a systematic review and meta-analyses

OBJECTIVE

To determine whether peripheral biochemical markers (biomarkers) might differentiate patients with attention-deficit/hyperactivity disorder (ADHD) from non-ADHD individuals.

METHOD

We conducted a systematic search and a series of meta-analyses of case-control studies comprising studies from 1969 to 2011.

RESULTS

We identified 210 studies in the following categories: 71 studies of the main metabolites and metabolism enzymes of monoaminergic neurotransmission pathway; 87 studies of environmental risk factors divided into heavy metals (18 studies), substance/chemical exposures (16 studies), and nutritional factors (trace elements: 29 studies; essential fatty acids: 24 studies); 22 studies of the hypothalamic-pituitary-adrenal axis (HPA) pathway; 31 studies indicated with "other". After screening for the availability for meta-analyses of drug naïve/free case-control studies and Bonferroni correction, five comparisons were statistically significant (Norepinephrine [NE], 3-Methoxy-4-hydroxyphenylethylene glycol [MHPG], monoamine oxidase [MAO], Zinc [Zn], cortisol), five of the significant findings found support in studies of response to ADHD medications (NE, MHPG, MAO, b-phenylethylamine [PEA], cortisol), six in studies of symptoms severity (NE, MHPG, MAO, ferritin, Zn, cortisol) and three in studies of neurophysiological or cognitive functioning (lead-ferritin-Zn). No evidence of publication bias was found, whereas significant heterogeneity of effect sizes across studies was found for three of the five biomarkers that differentiated ADHD from control subjects. Suggestive associations were evidenced for neuropeptide Y (NPY), manganese, and dehydroepiandrosterone (DHEA).

CONCLUSIONS

This study provides evidence for several peripheral biomarkers as being associated with ADHD both in diagnosis and in treatment efficacy. Further studies are warranted to replicate these findings, to assess their specificity for ADHD, and to quantify the degree to which they are sufficiently precise to be useful in clinical settings.

Bupropion versus methylphenidate in the treatment of children with attention-deficit/hyperactivity disorder: randomized double-blind study

OBJECTIVE

To compare the safety and efficacy of bupropion with methylphenidate in children and adolescents with attention-deficit/hyperactivity disorder (ADHD).

METHODS

In a 6-week randomized double-blind study, 44 patients with a DSM-IV-TR diagnosis of ADHD were randomly assigned to receive bupropion 100-150 mg/day (100 mg/day for <30 kg and 150 mg/day for >30 kg) or methylphenidate 20-30 mg/day. Symptoms were assessed using Teacher and Parent Attention-Deficit/Hyperactivity Disorder Rating Scale-IV (ADHD-RS-IV) at baseline and weeks 3 and 6.

RESULTS

Forty patients had at least one post-baseline measurement, and 38 patients completed the trial. No significant difference was found between the two groups on the Parent and Teacher ADHD-RS-IV scores ([F(1, 38) = 0.266, p = 0.609] and [F(1, 38) = 0.001, p = 0.972], respectively). By week 6, 18 patients (90%) in each group achieved response on the Parent scale (Fisher's exact test p-value = 1.0). With the Teacher ADHD-RS-IV used, eight (40%) patients in the bupropion group and 12 (60%) patients in the methylphenidate group achieved response by week 6 (χ(2) (1) = 1.600, p = 0.206). Headache was observed more frequently in the methylphenidate group. Frequency of other side effects was not significantly different between the two groups.

CONCLUSIONS

Bupropion has a comparable safety and efficacy profile with methylphenidate in children and adolescents with ADHD.

Salivary cortisol levels in prepubertal children using inhaled corticosteroids with or without concurrent intranasal corticosteroids

BACKGROUND

Inhaled corticosteroids (ICS) and intranasal steroids (INS) are frequently co-administered in children with asthma and rhinitis. In contrast to monotherapy with ICS or INS, little is known about the safety of concurrent use of topical steroids on hypothalamic-pituitary-adrenal (HPA) axis function in prepubertal children.

OBJECTIVE

Comparison of morning salivary cortisol levels in prepubertal children using maintenance treatment with ICS with and without concurrent use of INS to steroid naïve control groups (healthy children, and children with constipation who are under pediatric care).

METHODS

Cross-sectional observational study in prepubertal children (6-12 years) using ICS alone (n = 41) or in combination with INS (n = 22), compared to different control groups with no steroid treatment (18 healthy children, and 28 children with constipation). Morning salivary cortisol levels were determined from saliva samples collected at home.

RESULTS

The morning salivary cortisol levels of the healthy children (8.7 nmol/L; 95% CI 5.9-18.8), and the children with constipation (8.9 nmol/L; 8.0-11.3) were comparable. The salivary cortisol levels of prepubertal children using ICS (median 4.7 nmol/L; 95% CI 4.6-6.9) or a combination of ICS and INS (5.1 nmol/L; 4.2-7.6) were comparable, but significantly reduced compared to both control groups. There was no correlation between salivary cortisol level and age, duration of disease, or cumulative daily dose of topical steroids.

CONCLUSION

Salivary cortisol levels in prepubertal children using ICS, with or without concurrent use of INS, were comparable. However, salivary cortisol levels were significantly reduced compared to steroid naïve controls, irrespective of the cumulative daily dose of topical steroids. Pediatr. Pulmonol. 2011; 46:1055-1061. © 2011 Wiley Periodicals, Inc.

Association of salivary dehydroepiandrosterone levels and symptoms in patients with attention deficit hyperactivity disorder during six months of treatment with methylphenidate

This prospective study aimed to determine whether salivary levels of dehydroepiandrosterone (DHEA) in patients with attention deficit hyperactivity disorder (ADHD) change significantly during 6 months of treatment with methylphenidate (MPH), and to investigate long-term relationship between these levels and ADHD symptoms. Fifty ADHD patients aged between 6 and 12 years, and 50 age- and gender-matched healthy subjects were recruited. ADHD patients were prescribed oral MPH with a dose range of 5-15 mg/day at the discretion of the psychiatrist. DHEA levels were determined from saliva samples collected from both ADHD patients and healthy subjects at pretreatment and 1, 3, and 6 months from pretreatment visit. ADHD symptoms were evaluated with the Swanson, Nolan, and Pelham, Version IV Scale for ADHD and the ADHD Rating Scale, and computerized Continuous Performance Test (CPT). The results showed that salivary DHEA levels significantly increased in ADHD patients during the 6-month course of methylphenidate treatment, but the DHEA levels did not significantly change in the untreated healthy group during the 6-month period of natural observation. For the longitudinal observation, among ADHD patients, the salivary DHEA levels were independently correlated with distraction and impulsivity performance in the CPT, but not correlated with inattention and hyperactivity in the clinical ADHD symptoms. Whether DHEA exerts effects on neurocognitive functions as mediators or independently of MPH warrants further investigation.

Salivary dehydroepiandrosterone, but not cortisol, is associated with attention deficit hyperactivity disorder

OBJECTIVES

The purposes of this study were to determine whether salivary levels of dehydroepiandrosterone (DHEA) and cortisol are associated with attention deficit hyperactivity disorder (ADHD) or correlated with performance on the Continuous Performance Test (CPT).

METHODS

Fifty ADHD patients and 50 age- and gender-matched controls aged between 6 and 12 years were included in this cross-sectional study. DHEA and cortisol levels were determined from saliva samples collected by the passive drool method at 08:00 h. ADHD patients subsequently performed a computerized Continuous Performance Test (CPT). ADHD symptoms were evaluated with the Swanson, Nolan, and Pelham, Version IV Scale for ADHD (SNAP-IV), completed by the patients' parents, and with the ADHD Rating Scale (ADHD-RS), administered by a child psychiatrist.

RESULTS

Saliva DHEA levels and DHEA/cortisol ratios differed significantly between ADHD patients and controls. Among ADHD patients, saliva DHEA levels and DHEA/cortisol ratios were independently correlated with composite scores of CPT distractibility and CPT impulsivity. Basal levels of cortisol were not significantly associated with ADHD.

CONCLUSIONS

DHEA, but not the cortisol basal level, may be a biological laboratory marker for ADHD, particularly for performance on the CPT. Both the causal relationship between DHEA and ADHD and the role of DHEA in treating ADHD require further investigation.

Neurosteroid blood levels in delinquent adolescent boys with conduct disorder

Accumulating data indicates that neurosteroids can modulate aggressive behavior. The aim of the present study was to examine neurosteroid blood levels in delinquent adolescent boys as compared to normal healthy controls. Dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEA-S) and cortisol blood levels were measured in 16 delinquent adolescent (age 15.72+/-0.95 years) with conduct disorder (CD) and 11 normal controls (16.82+/-1.83 years). Severity of aggressive behavior was assessed by the Child Behavior Checklist (CBCL) and the Overt Aggression Scale (OAS). The delinquent adolescents tended to have higher DHEA-S levels than the normal control group (p=0.054). DHEA and cortisol levels did not differ between the two groups. The interaction between neurosteroids ( especial DHEA-S) and genetic, developmental and environmental factors in juvenile delinquency merits further investigation.

Moderate versus severe early life stress: associations with stress reactivity and regulation in 10-12-year-old children

Early life stress (ELS) is expected to increase reactivity of the hypothalamic-pituitary-adrenocortical (HPA) axis; however, several recent studies have shown diminished cortisol reactivity among adults and children with ELS exposure. The goal of this study was to examine cortisol activity in 10-12-year-old internationally adopted children to determine if moderate and severe ELS have different impacts on the HPA axis. Salivary cortisol and two measures of autonomic activity were collected in response to the Trier Social Stress Test for Children (TSST-C). Three groups reflecting moderate, severe, and little ELS were studied: early adopted children who came predominantly from foster care overseas (early adopted/foster care (EA/FC), n=44), later adopted children cared for predominantly in orphanages overseas (late adopted/post-institutionalized (LA/PI), n=42) and non-adopted (NA) children reared continuously by their middle- to upper-income parents in the United States (n=38). Diminished cortisol activity was noted for the EA/FC group (moderate ELS), while the LA/PI group (severe ELS) did not differ from the NA group. Overall, few children showed cortisol elevations to the TSST-C in any group. The presence/absence of severe growth delay at adoption proved to be a critical predictive factor in cortisol activity. Regardless of growth delay, however, LA/PI children exhibited higher sympathetic tone than did NA children. These results suggest that moderate ELS is associated with diminished cortisol activity; however, marked individual differences in cortisol activity among the LA/PI children suggest that child factors modify the impact of severe ELS. Lack of effects of severe ELS even for growth delayed children may reflect the restorative effects of adoption or the generally low responsiveness of this age group to the TSST-C.