Efficacy and Safety of Medication for Attention-Deficit Hyperactivity Disorder in Children and Adolescents with Common Comorbidities: A Systematic Review

The High Rates of Comorbidity among Neurodevelopmental Disorders: Reconsidering the Clinical Utility of Distinct Diagnostic Categories

The boundaries between neurodevelopmental disorders are often indistinct, even among specialists. But do these boundaries exist, or do experts struggle to distinguish and categorize symptoms in order to arrive at a dominant diagnosis while comorbidity continually leaves questions about where each disorder ends and begins? What should be reconsidered? The introduction of the term 'spectrum of neurodevelopmental disorders' could pave the way for a re-appraisal of the clinical continuum of neurodevelopmental disorders. This study aims to highlight the problems that emerge in the field of the differential diagnosis of neurodevelopmental disorders and propose a renegotiation of the distinctiveness criteria.

Risk of Overweight and Obesity in Children and Adolescents With Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis

This study was performed to explore the association between attention-deficit/hyperactivity disorder (ADHD) and the risk of overweight/obesity in both children and adolescents. The PubMed, Web of Science, and Cochrane Library databases were searched for relevant studies published before July 12, 2022. Studies with data for calculating the odds ratio (OR) of childhood overweight/obesity and ADHD were included. The literature value was assessed by the cross-sectional evaluation criteria proposed by the Agency for Healthcare Research and Quality (AHRQ). All analyses were conducted using StataSE 11 and RevMan 5.3 software with random-effects models. This review included a total of 16 studies covering 14,981 cases and 128,916 controls.According to the meta-analysis, children with ADHD had a significant risk for co-occurring overweight and obesity [OR 1.56; 95% confidence intervals (CI) 1.32-1.85], especially boys (OR 1.45; 95% CI 1.10-1.90), people in Asia (OR 3.25; 95% CI 1.70-6.21) and Europe (OR 1.85; 95% CI 1.61-2.12), and patients not using medication (OR 1.54; 95% CI 1.22-1.94).ADHD has a significant association with overweight and obesity in both children and adolescents, which may be altered by factors such as geography, gender, and medication use. Timely treatment should be provided to children and adolescents diagnosed with ADHD to inhibit the emergence of overweight and obesity.

A systematic meta-review of systematic reviews on attention deficit hyperactivity disorder

BACKGROUND

There are now hundreds of systematic reviews on attention deficit hyperactivity disorder (ADHD) of variable quality. To help navigate this literature, we have reviewed systematic reviews on any topic on ADHD.

METHODS

We searched MEDLINE, PubMed, PsycINFO, Cochrane Library, and Web of Science and performed quality assessment according to the Joanna Briggs Institute Manual for Evidence Synthesis. A total of 231 systematic reviews and meta-analyses met the eligibility criteria.

RESULTS

The prevalence of ADHD was 7.2% for children and adolescents and 2.5% for adults, though with major uncertainty due to methodological variation in the existing literature. There is evidence for both biological and social risk factors for ADHD, but this evidence is mostly correlational rather than causal due to confounding and reverse causality. There is strong evidence for the efficacy of pharmacological treatment on symptom reduction in the short-term, particularly for stimulants. However, there is limited evidence for the efficacy of pharmacotherapy in mitigating adverse life trajectories such as educational attainment, employment, substance abuse, injuries, suicides, crime, and comorbid mental and somatic conditions. Pharmacotherapy is linked with side effects like disturbed sleep, reduced appetite, and increased blood pressure, but less is known about potential adverse effects after long-term use. Evidence of the efficacy of nonpharmacological treatments is mixed.

CONCLUSIONS

Despite hundreds of systematic reviews on ADHD, key questions are still unanswered. Evidence gaps remain as to a more accurate prevalence of ADHD, whether documented risk factors are causal, the efficacy of nonpharmacological treatments on any outcomes, and pharmacotherapy in mitigating the adverse outcomes associated with ADHD.

Effect of physical activity on attention in school-age children with ADHD: a systematic review and meta-analysis of randomized controlled trials

Background: Attention problems are one of the core symptoms of Attention-deficit/hyperactivity disorder (ADHD) in children. Previous studies have shown that physical activity intervention has a positive impact on executive function in children and adolescents with ADHD, but there is limited research on attention problems in school-aged children with ADHD. There are still uncertainties about the appropriate physical activity interventions to improve attention problems in this population. This study conducted a Meta-analysis of randomized controlled trials (RCTs) related to physical activity intervention for attention problems in school-aged children with ADHD, providing a certain reference for precise intervention in attention problems for this population. Methods: We systematically searched the following databases up to October 2022: PubMed, Embase, Web of Science, and Cochrane Library, to identify RCTs that investigated the effects of physical activity interventions on children with ADHD. Two investigators independently conducted literature screening, extraction, and quality assessment. We performed a meta-analysis using Stata 15.1. Results: In total, we included 10 studies in this meta-analysis. The results indicated that physical activity intervention had a moderate effect in improving attention problems in school-aged children with ADHD (SMD = -0.48, 95% CI: 0.85, -0.07, p < 0.05). Furthermore, subgroup analysis showed that the effect of physical activity intervention was moderated by intervention type, frequency, and period, rather than the physical activity environment or single intervention time. Conclusion: Our study suggests that cognitively engaging exercise is more effective in improving attention problems in school-aged children with ADHD. Specifically, when cognitive-engaging exercise is used as the type of physical activity and the intervention frequency is less than 3 times per week, with an intervention period of less than weeks, it is most beneficial for improving attention problems in school-aged children with ADHD. However, we should also consider individual differences in children with respect to their ADHD symptoms and accurately evaluate each child's specific symptoms before intervention. Systematic Review Registration: identifier (CRD42022363255).

Efficacy and Safety of PRC-063 for Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-analysis From Randomized Controlled Trials

OBJECTIVE

A new formulation of extended-release methylphenidate (PRC-063) was approved to treat ADHD. This meta-analysis was conducted to study the efficacy and safety of PRC-063 for ADHD.

METHOD

We searched for published trials to October 2022 in several databases.

RESULTS

A total of 1,215 patients from 5 RCTs were included. We observed significant improvement for PRC-063 in ADHD Rating Scale (ADHD-RS; MD = -6.73, 95% CI [-10.34, -3.12]) compared with placebo. The effect of PRC-063 on the sleep problems due to ADHD was not statistically different from placebo. Six subscales of Pittsburg Sleep Quality Index (PSQI) showed no statistical significance between PRC-063 and placebo. The result showed no significant difference comparing PRC-063 with placebo in serious treatment-emergent adverse events (TEAEs) (RR = 0.80, 95% CI [0.03, 19.34]). In subgroup analysis according to age, PRC-063 was more efficacious in minors compare to adults.

CONCLUSION

PRC-063 is an efficacious and safe treatment for ADHD, especially in children and adolescents.

Personalizing atomoxetine dosing in children with ADHD: what can we learn from current supporting evidence

PURPOSE

There is marked heterogeneity in treatment response of atomoxetine in patients with attention deficit/hyperactivity disorder (ADHD), especially for the pediatric population. This review aims to evaluate current evidence to characterize the dose-exposure relationship, establish clinically relevant metrics for systemic exposure to atomoxetine, define a therapeutic exposure range, and to provide a dose-adaptation strategy before implementing personalized dosing for atomoxetine in children with ADHD.

METHODS

A comprehensive search was performed across electronic databases (PubMed and Embase) covering the period of January 1, 1985 to July 10, 2022, to summarize recent advances in the pharmacokinetics, pharmacogenomics/pharmacogenetics (PGx), therapeutic drug monitoring (TDM), physiologically based pharmacokinetics (PBPK), and population pharmacokinetics (PPK) of atomoxetine in children with ADHD.

RESULTS

Some factors affecting the pharmacokinetics of atomoxetine were summarized, including food, CYP2D6 and CYP2C19 phenotypes, and drug‒drug interactions (DDIs). The association between treatment response and genetic polymorphisms of genes encoding pharmacological targets, such as norepinephrine transporter (NET/SLC6A2) and dopamine β hydroxylase (DBH), was also discussed. Based on well-developed and validated assays for monitoring plasma concentrations of atomoxetine, the therapeutic reference range in pediatric patients with ADHD proposed by several studies was summarized. However, supporting evidence on the relationship between systemic atomoxetine exposure levels and clinical response was far from sufficient.

CONCLUSION

Personalizing atomoxetine dosage may be even more complex than anticipated thus far, but elucidating the best way to tailor the non-stimulant to a patient's individual need will be achieved by combining two strategies: detailed research in linking the pharmacokinetics and pharmacodynamics in pediatric patients, and better understanding in nature and causes of ADHD, as well as environmental stressors.

Decision aid development and its acceptability among adults with attention-deficit/hyperactivity disorders regarding treatment discontinuation after remission

Aim

Current clinical guidelines for attention-deficit/hyperactivity disorder (ADHD) put shared decision making (SDM) at the center of care. However, there remain challenges in SDM in ADHD management, particularly regarding the decision to continue or discontinue medication after ADHD remission in adult patients. We aimed to develop a decision aid (DA) for adult patients with ADHD regarding the continuation or discontinuation of their ongoing ADHD medications after they have attained remission.

Method

We systematically developed a DA according to the International Patient Decision Aid Standard (IPDAS). First, we created a DA prototype using the results of our previous systematic review and meta-analysis that identified the consequences of continuing and discontinuing ADHD medications. Second, we administered a mixed-method questionnaire (alpha acceptability testing) to adult patients with ADHD and healthcare providers to improve the DA prototype and develop it into a final version that is acceptable for clinical settings.

Results

Our DA consisted of ADHD description, the option to continue or discontinue ADHD medications, the advantages and disadvantages of the consequences, as well as value clarification exercises for each option. Patients (n = 20) reported that the DA had acceptable language (85%), adequate information (75%), and a well-balanced presentation (53%). Healthcare providers (n = 19) provided favorable feedback. The final DA met all six IPDAS requisite criteria.

Conclusions

Our results could facilitate the SDM process between patients and healthcare providers on the continuation or discontinuation of ADHD medication following remission. Further studies should verify the effects of using the DA during the SDM process among patients across the age spectrum with ADHD and healthcare providers.

A perspective on molecular signalling dysfunction, its clinical relevance and therapeutics in autism spectrum disorder

Intellectual disability (ID) and autism spectrum disorder (ASD) are neurodevelopmental disorders that have become a primary clinical and social concern, with a prevalence of 2-3% in the population. Neuronal function and behaviour undergo significant malleability during the critical period of development that is found to be impaired in ID/ASD. Human genome sequencing studies have revealed many genetic variations associated with ASD/ID that are further verified by many approaches, including many mouse and other models. These models have facilitated the identification of fundamental mechanisms underlying the pathogenesis of ASD/ID, and several studies have proposed converging molecular pathways in ASD/ID. However, linking the mechanisms of the pathogenic genes and their molecular characteristics that lead to ID/ASD has progressed slowly, hampering the development of potential therapeutic strategies. This review discusses the possibility of recognising the common molecular causes for most ASD/ID based on studies from the available models that may enable a better therapeutic strategy to treat ID/ASD. We also reviewed the potential biomarkers to detect ASD/ID at early stages that may aid in diagnosis and initiating medical treatment, the concerns with drug failure in clinical trials, and developing therapeutic strategies that can be applied beyond a particular mutation associated with ASD/ID.

Methylphenidate Use for Emotional Dysregulation in Children and Adolescents with ADHD and ADHD and ASD: A Naturalistic Study

Emotional dysregulation (ED) is common in attention-deficit/hyperactivity disorder (ADHD). Nonetheless, research on ADHD in children with autism spectrum disorder (ASD) and ADHD is still ongoing. Several studies suggest that methylphenidate (MPH) may be effective for ED in ADHD, while there is not enough evidence about its use in ASD with comorbid ADHD. This naturalistic study aims to investigate the effectiveness of immediate- and extended-release MPH in the treatment of ED in 70 children and adolescents (6–18 years), with a diagnosis of ADHD (n = 41) and of ASD with comorbid ADHD (n = 29), using the Child Behavior Checklist—Attention/Aggressive/Anxious (CBCL-AAA). Their parents completed the CBCL twice—first during the summer medication-free period, that is, at least one month after drug interruption; and again after three months of treatment restart. Results demonstrate that MPH is associated with a statistically significant reduction in ED in ADHD and ASD, without substantial adverse events, supporting the use of psychostimulants for the treatment of ED in these neurodevelopmental disorders.

The Mechanism, Clinical Efficacy, Safety, and Dosage Regimen of Atomoxetine for ADHD Therapy in Children: A Narrative Review

Atomoxetine, a selective norepinephrine (NE) reuptake inhibitor, was approved for attention deficit/hyperactivity disorder (ADHD) treatment in children, adolescents and adults. We searched the database PubMed/MEDLINE (2000 to October 1, 2021). Only publications in English were considered. Atomoxetine inhibits the presynaptic norepinephrine transporter (NET), preventing the reuptake of NE throughout the brain along with inhibiting the reuptake of dopamine in specific brain regions such as the prefrontal cortex (PFC). The novel mechanism of atomoxetine also includes several new brain imaging studies and animal model studies. It is mainly metabolized by the highly polymorphic drug metabolizing enzyme cytochrome P450 2D6 (CYP2D6). Atomoxetine is effective and generally well tolerated. ADHD is often accompanied by multiple comorbidities. A series of studies have been published suggesting that atomoxetine is effective in the treatment of ADHD symptoms for children with various types of comorbidity. In some cases, it is possible that atomoxetine may have a positive influence on the symptoms of comorbidities. Atomoxetine can be administered either as a single daily dose or split into two evenly divided doses, and has a negligible risk of abuse or misuse. The latest guideline updated that clinical dose selection of atomoxetine was recommended based on both CYP2D6 genotype and the peak concentration. To have a more comprehensive understanding of atomoxetine, this review sets the focus on the mechanism, clinical efficacy and dosage regimen in detail, and also touches on those studies regarding adverse reactions of atomoxetine.