Impact of Attention-Deficit Hyperactivity Disorder on School Performance: What are the Effects of Medication?

Clarifying the relationship and analyzing the influential factors of bronchial asthma in children with attention-deficit hyperactivity disorder

BACKGROUND

Bronchial asthma is closely related to the occurrence of attention-deficit hyperactivity disorder (ADHD) in children, which can easily have adverse effects on children's learning and social interactions. Studies have shown that childhood asthma can increase the risk of ADHD and the core symptoms of ADHD. Compared with children with ADHD alone, children with asthma and ADHD are more likely to show high levels of hyperactivity, hyperactive-impulsive and other externalizing behaviors and anxiety in clinical practice and have more symptoms of somatization and emotional internalization.

AIM

To explore the relationship between ADHD in children and bronchial asthma and to analyze its influencing factors.

METHODS

This retrospective cohort study was conducted at Dongying People's Hospital from September 2018 to August 2023. Children diagnosed with ADHD at this hospital were selected as the ADHD group, while healthy children without ADHD who underwent physical examinations during the same period served as the control group. Clinical and parental data were collected for all participating children, and multivariate logistic regression analysis was employed to identify risk factors for comorbid asthma in children with ADHD.

RESULTS

Significant differences were detected between the ADHD group and the control group in terms of family history of asthma and allergic diseases, maternal complications during pregnancy, maternal use of asthma and allergy medications during pregnancy, maternal anxiety and depression during pregnancy, and parental relationship status (P < 0.05). Out of the 183 children in the ADHD group, 25 had comorbid asthma, resulting in a comorbidity rate of 13.66% (25/183), compared to the comorbidity rate of 2.91% (16/549) among the 549 children in the control group. The difference in the asthma comorbidity rate between the two groups was statistically significant (P < 0.05). The results of the multivariate logistic regression analysis indicated that family history of asthma and allergic diseases, maternal complications during pregnancy, maternal use of asthma and allergy medications during pregnancy, maternal anxiety and depression during pregnancy, and parental relationship status are independent risk factors increasing the risk of comorbid asthma in children with ADHD (P < 0.05).

CONCLUSION

Children with ADHD were more likely to have comorbid asthma than healthy control children were. A family history of asthma, adverse maternal factors during pregnancy, and parental relationship status were identified as risk factors influencing the comorbidity of asthma in children with ADHD. Clinically, targeted interventions based on these factors can be implemented to reduce the risk of comorbid asthma. This information is relevant for results sections of abstracts in scientific articles.

Treatment Utilization Pattern of Preschool Children With Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

The aim of this study was to identify patterns of ADHD care, including factors that guide selection and sequencing of treatments in a large nationwide sample of preschool-aged youth over the past 6 years.

METHOD

A retrospective cohort study utilizing a large electronic health record (TriNetX) of nearly 24,000 children ages 3 to 6 diagnosed with ADHD.

RESULTS

One in three preschoolers with ADHD were prescribed psychotropic medication, most commonly methylphenidate and guanfacine. One in 10 had at least one psychotherapy billing code during the entire assessment with most youth starting medication before psychotherapy. Rates of most treatments, including polypharmacy, increased with comorbid psychiatric disorders or sleep problems and over the course of the coronavirus pandemic.

CONCLUSION

Rates of treatment have increased over time but are still largely inconsistent with published care guidelines that advise therapy before medication. Clinicians appear to prioritize psychiatric comorbidity and sleep problems when selecting treatments.

A post hoc analysis of the effect of viloxazine extended-release capsules on learning and school problems in children and adolescents with attention-deficit/hyperactivity disorder

Improvement in attention-deficit/hyperactivity disorder (ADHD) symptoms vs. placebo was reported in a series of pediatric clinical trials of viloxazine extended-release capsules (viloxazine ER; Qelbree™). This post hoc analysis of those studies evaluated the effect of viloxazine ER on learning and school problems (LSPs). We used data from four Phase 3 placebo-controlled trials of 100-600 mg/day viloxazine ER (N = 1354; 6-17 years of age). LSPs were evaluated using the School domain of the Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P-S) and the Learning Problems content scale of the Conners 3rd Edition-Parent Short Form (C3PS-LP) at baseline and end of study (≥ Week 6). ADHD symptoms were assessed weekly using the ADHD Rating Scale 5th Edition. The analyses were performed using the general linear mixed model with participant as a random effect. The responder analyses were performed using the Chi-square test. Viloxazine ER demonstrated significantly greater improvements in WFIRS-P-S (p < 0.0001) and C3PS-LP (p = 0.0113) scores vs. placebo. The response rate for the WFIRS-P-S was significantly greater for viloxazine ER vs. placebo (p = 0.001), and the number needed to treat (NNT) was 10.3 (effect size 0.7). Conversely, response rates for C3PS-LP did not differ between groups (p = 0.9069). In addition to ADHD symptoms improvement demonstrated in previous studies, viloxazine ER significantly reduced LSPs in pediatric subjects with ADHD. The responder analyses and NNT estimates indicate that a substantial number of children and adolescents with ADHD treated with viloxazine ER improved in clinically assessed LSPs.

The impact of attention-deficit/hyperactivity disorder and specific learning disorders on academic performance in Spanish children from a low-middle- and a high-income population

Introduction

Past research has demonstrated that attention-deficit/hyperactivity disorder (ADHD), specific learning disorders (SLD), and socioeconomic status (SES) affect a host of educational outcomes. However, there are no studies examining whether SES moderates the association between these neurodevelopmental disorders (ND) and the academic achievement of children and adolescents. The present investigation examined the impact of ADHD and SLD on academic performance in 1,287 Spanish students aged 5-17 from a low-middle (LM)- and a high-income population, when adjusted for comorbidity and demographic factors that may influence educational functioning.

Methods

Parents completed a questionnaire regarding demographic data along with the Strengths and Difficulties Questionnaire. Additionally, teachers provided information on learning difficulties trough the Protocol for Detection and Management of Dyslexia. Teacher's Version. Academic performance across multiple domains (i.e., first language, foreign language, mathematics) was obtained from school records. ND were determined using standardized diagnostic methods based on the Diagnostic and Statistical Manual of Mental Disorders criteria. To examine the effects of ADHD and SLD on academic achievement and the potential moderating role of SES, a series of ordinal logistic regressions were conducted.

Results

Emotional/behavioral problems, learning difficulties, and ND were more frequent among individuals from the LM-income population. After controlling for gender, age, parental divorce/separation, grade retention, frequency of screen use, and daily meals, both ADHD and SLD were associated with worse educational outcomes. Lower SES also increased the risk for academic impairment, although the interactions with ADHD or SLD were not significant.

Conclusion

These findings indicate that ADHD and SLD exert a pervasive impact on academic performance across different socioeconomic backgrounds. Therefore, early detection and effective intervention strategies aimed at students with these ND are crucial to improve their educational functioning and mitigate the negative consequences related to academic problems.

Evaluating the pharmacokinetics of extended release viloxazine in the treatment of children with attention-deficit/hyperactivity disorder

INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder of childhood and impacts function negatively in multiple settings. Current treatments include stimulants, which inhibit the reuptake of dopamine and norepinephrine, a nonstimulant norepinephrine reuptake inhibitor (NRI) atomoxetine, and alpha-2 agonists clonidine extended release (ER) and guanfacine ER. Despite the effectiveness of these medications some patients do not respond to available drugs or may experience tolerability issues that hinder their use.

AREAS COVERED

Viloxazine, a serotonin norepinephrine modulating agent, was used outside of the United States (U.S.) as an effective antidepressant for several decades, but its use fell out of favor due to the need for multiple daily dosing. An ER viloxazine formulation was recently approved by the U. S. Food and Drug Administration (FDA) for the treatment of ADHD. The efficacy, pharmacokinetics and metabolism of viloxazine and viloxazine ER are reviewed.

EXPERT OPINION

Viloxazine ER is the first nonstimulant approved to treat ADHD in more than a decade. Although they have not been directly compared, the effect size of viloxazine ER is less than has been observed for stimulants. However, its pharmacokinetic properties and tolerability make viloxazine ER a useful addition to the collection of FDA approved ADHD treatments.

Is genetic liability to ADHD and ASD causally linked to educational attainment?

BACKGROUND

The association patterns of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) with educational attainment (EA) are complex; children with ADHD and ASD are at risk of poor academic outcomes, and parental EA has been associated with risk of ADHD/ASD in the offspring. Little is known on the causal links between ADHD, ASD, EA and the potential contribution of cognitive ability.

METHODS

Using the latest genome-wide association studies (GWAS) summary data on ADHD, ASD and EA, we applied two-sample Mendelian randomization (MR) to assess the effects of genetic liability to ADHD and ASD on EA. Reverse direction analyses were additionally performed. Multivariable MR was performed to estimate any effects independent of cognitive ability.

RESULTS

Genetic liability to ADHD had a negative effect on EA, independently of cognitive ability (MVMRIVW: -1.7 months of education per doubling of genetic liability to ADHD; 95% CI: -2.8 to -0.7), whereas genetic liability to ASD a positive effect (MVMRIVW: 30 days per doubling of the genetic liability to ASD; 95% CI: 2 to 53). Reverse direction analyses suggested that genetic liability to higher EA had an effect on lower risk of ADHD, independently of cognitive ability (MVMRIVWOR: 0.33 per SD increase; 95% CI: 0.26 to 0.43) and increased risk of ASD (MRIVWOR: 1.51 per SD increase; 95% CI: 1.29 to 1.77), which was partly explained by cognitive ability (MVMRIVWOR per SD increase: 1.24; 95%CI: 0.96 to 1.60).

CONCLUSIONS

Genetic liability to ADHD and ASD is likely to affect educational attainment, independently of underlying cognitive ability.

Gray Matter Network Associated With Attention in Children With Attention Deficit Hyperactivity Disorder

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is one of the most prevalent childhood-onset neurodevelopmental disorders; however, the underlying neural mechanisms for the inattention symptom remain elusive for children with ADHD. At present, the majority of studies have analyzed the structural MRI (sMRI) with the univariate method, which fails to demonstrate the interregional covarying relationship of gray matter (GM) volumes among brain regions. The scaled subprofile model of principal component analysis (SSM-PCA) is a multivariate method, which can detect more robust brain-behavioral phenotype association compared to the univariate analysis method. This study aims to identify the GM network associated with attention in children with ADHD by applying SSM-PCA to the sMRI.

METHODS

The sMRI of 209 children with ADHD and 209 typically developing controls (TDCs) aged 7-14 years from the ADHD-200 dataset was used for anatomical computation, and the GM volume in each brain region was acquired. Then, SSM-PCA was applied to the GM volumes of all the subjects to capture the GM network of children with ADHD (i.e., ADHD-related pattern). The relationship between the expression of ADHD-related pattern and inattention symptom was further investigated. Finally, the influence of sample size on the analysis of this study was explored.

RESULTS

The ADHD-related pattern mainly included putamen, pallium, caudate, thalamus, right accumbens, superior/middle/inferior frontal cortex, superior occipital cortex, superior parietal cortex, and left middle occipital cortex. In addition, the expression of the ADHD-related pattern was related to inattention scores measured by the Conners' Parent Rating Scale long version (CPRS-LV; r = 0.25, p = 0.0004) and the DuPaul ADHD Rating Scale IV (ADHD-RS; r = 0.18, p = 0.03). Finally, we found that when the sample size was 252, the results of ADHD-related pattern were relatively reliable. Similarly, the sample size needed to be 162 when exploring the relationship between ADHD-related pattern and behavioral indicator measured by CPRS-LV.

CONCLUSION

We captured a GM network associated with attention in children with ADHD, which is different from that in adolescents and adults with ADHD. Our findings may shed light on the diverse neural mechanisms of inattention and provide treatment targets for children with ADHD.

The relationship between cognition and mathematics in children with attention-deficit/hyperactivity disorder: a systematic review

Cognitive processes play an imperative role in children's mathematics learning. Difficulties in cognitive functioning are a core feature of Attention Deficit Hyperactivity Disorder (ADHD) in children, who also tend to show lower levels of mathematics attainment than their typically developing peers. This review (registration number: CRD42020169708) sought to aggregate findings from studies assessing the relationship between cognition and mathematics in children with a clinical ADHD diagnosis aged 4-12 years. A total of 11,799 studies published between 1992 and August 2020 were screened for eligibility using various database (PsycINFO, PubMed, SCOPUS, EMBASE, ERIC, Web of Science, and additional sources), from which four studies met inclusion criteria. A narrative synthesis was conducted on the correlations between mathematics and cognitive domains, including an evaluation of the risk of bias within the studies. Across four studies meeting inclusion criteria, memory, inhibitory control, and processing speed were assessed. The results showed a positive association between cognition and mathematics performance in this population. The strength of associations across these studies varied as a function of the cognitive domain in question, means by which mathematics performance was assessed, as well as whether confounding factors such as age and IQ were controlled for. Collectively, this review demonstrates a lack of research in this area and points to various methodological considerations for identifying the association between cognition and mathematics performance in ADHD.

Desempenho em Aritmética de Estudantes com e sem Sintomas de TDAH

Resumo O Transtorno de Déficit de Atenção/Hiperatividade (TDAH) é um transtorno que frequentemente acarreta prejuízos ao desempenho acadêmico. O presente estudo teve como objetivo verificar a extensão desses prejuízos no desempenho aritmético, comparando estudantes com sintomas de TDAH com o de seus pares sem TDAH. O desempenho aritmético de 93 estudantes com sintomas de TDAH e 447 estudantes sem TDAH, entre 7 e 16 anos, de escolas públicas de Porto Alegre (3º a 9º ano), foi avaliado pelo Subteste de Aritmética do TDE. Estudantes com sintomas de TDAH apresentaram escores mais baixos e uma quantidade maior de erros de procedimento do que os estudantes sem o transtorno. Os resultados sugerem que sintomas frequentes de TDAH têm relação com maior ocorrência de erros no desempenho em aritmética dos estudantes avaliados neste estudo.

"Real-world" effectiveness of methylphenidate in improving the academic achievement of Attention-Deficit Hyperactivity Disorder diagnosed students-A systematic review

WHAT IS KNOWN AND OBJECTIVE

Attention-deficit hyperactivity disorder (ADHD) symptoms usually impairs academic achievement and can trigger the onset of medication. Methylphenidate is a drug widely prescribed to treat ADHD. However, systematic reviews of randomized clinical trials suggest that it does not lead to great improvements in academic performance. Thus, we aimed to evaluate the evidence on the "real-world" effectiveness of methylphenidate in improving the academic achievement of ADHD students.

METHODS

We conducted a systematic review of observational studies retrieved from five electronic databases, besides a manual search and search in grey literature. Studies evaluating treatment with methylphenidate compared to no treatment or other pharmacological/non-pharmacological alternatives used in ADHD were included. The risk of bias of the selected studies was assessed using adapted versions of the Newcastle-Ottawa Scale.

RESULTS AND DISCUSSION

Nine studies (from ten reports) were included in the review: four cohorts, two before-and-after designs and three cross-sectional studies. They involved 12,269 children and adolescents aged 6-18 years. The doses of methylphenidate ranged from 10 to 72 mg/day, and the duration of the treatment from 2.6 months to 4.25 years. Five of these studies concluded that methylphenidate improves academic performance. However, three of the four lowest-bias risk studies concluded that the drug is ineffective. Five studies assessed the long-term use of methylphenidate, and four of them concluded that it does not result in better outcomes in the school setting. Most included studies had considerable limitations and significant heterogeneity regarding methodological design and academic performance measurement criteria.

WHAT IS NEW AND CONCLUSION

Although some studies indicate that the short-term use of methylphenidate may improve outcomes in the school environment, the available evidence does not support the establishment of adequate conclusions about the real benefits of methylphenidate in the academic improvement of ADHD students.

A longitudinal investigation of cognitive functioning and its relationship to symptom severity and academic functioning in treatment seeking youth with AHDH

Background:

Children with ADHD tend to present with poorer cognitive functioning leaving them more vulnerable to a range of negative outcomes. To date, only a handful of longitudinal studies have examined the stability of Wechsler composite scores in children and adolescents with ADHD, and none of them used a more recent version of the Wechsler Intelligence Scales for Children (WISC), than the WISC-III.

Objective:

The present study investigates the cognitive stability and its longitudinal relationship with the severity of the child’s ADHD symptoms and school grades.

Method:

Cognitive functioning was measured with the fourth editions of the WISC-IV or the Wechsler Adult Intelligence Scales (WAIS-IV) at baseline and at a 3-4-year follow-up in children with ADHD (n = 125, mean age = 11.40 years, SD = 3.27) and a Control group of schoolchildren (n = 59, mean age = 11.97 years, SD = 2.15). The stability of cognitive functioning and the relationship between cognitive functioning, ADHD and grades were evaluated using linear mixed models and logistic regression.

Results:

Standardized composite scores of Full scale IQ, Verbal Comprehension, and Processing Speed declined between baseline and follow-up in the ADHD group. ADHD symptom scores were associated with Working Memory scores. Together, the severity of concurrent ADHD symptoms and lower scores for verbal comprehension at baseline and follow-up were associated with an increased risk of not achieving grades at follow-up in youth with ADHD.

Conclusions:

Youth with ADHD often present with cognitive impairments, not improved over time. Together these increase the risk of poorer academic outcomes. Concurrent evaluation of symptom severity and cognitive functions can add potentially useful information in terms of treatment planning, and school supports to prevent school failure.

Once-Daily SPN-812 200 and 400 mg in the treatment of ADHD in School-aged Children: A Phase III Randomized, Controlled Trial

PURPOSE

SPN-812 (viloxazine extended-release) is under investigation for the treatment of attention-deficit/hyperactivity disorder (ADHD) in children and adolescents. This Phase III study evaluated the efficacy and tolerability of SPN-812 200 and 400 mg once daily in children 6-11 years of age with ADHD.

METHODS

Patients were randomly assigned to receive SPN-812 200 mg, SPN-812 400 mg, or placebo, once daily for 8 weeks (including ≤3 weeks titration period). The primary efficacy endpoint was the change from baseline (CFB) in ADHD Rating Scale (RS)-5 Total score at end of study (EOS). Key secondary endpoints included Clinical Global Impression-Improvement (CGI-I) score at EOS, CFB in Conners 3-Parent Short Form (PS) composite T-score at EOS, and CFB in Weiss Functional Impairment Rating Scale-Parent (WFIRS-P) Total average score at EOS.

FINDINGS

A total of 313 patients were enrolled, with 301 in the intent-to-treat population (194 boys, 107 girls; mean age [SD], 8.4 [1.7] years). At EOS, the CFBs in ADHD-RS-5 Total score and CGI-I score were significantly improved with both 200- and 400-mg/d SPN-812 versus placebo (ADHD-RS-5, P = 0.0038 and 0.0063, respectively; CGI-I, P = 0.0028 and 0.0099). At EOS, the CFB in Conners 3-PS composite T-score was significantly improved with 200- (P = 0.0064), but not 400-mg/d (P = 0.0917), SPN-812 compared to placebo. No significant difference between the groups was found in WFIRS-P Total average score. The rate of discontinuations due to adverse events in both SPN-812 treatment groups combined was <5%.

IMPLICATIONS

SPN-812 200 and 400 mg once daily was associated with improvements in ADHD symptoms in school-aged children and was generally well tolerated. ClinicalTrials.gov identifier: NCT03247543.

Sleep, academic achievement, and cognitive performance in children with attention-deficit hyperactivity disorder: A polysomnographic study

The objective of this study was to examine the influence of parent-reported and polysomnography (PSG)-measured sleep patterns on the academic and cognitive performance of children with attention-deficit hyperactivity disorder (ADHD). We assessed 91 children (18 girls) diagnosed with ADHD aged 7-11 years (29 ADHD-Inattentive, 32 ADHD-Hyperactive/Impulsive, and 31 ADHD-Combined). The Paediatric Sleep Questionnaire (PSQ) and Paediatric Daytime Sleepiness Scale (PDSS) were used to assess subjective sleep quality, as perceived by parents, and objective sleep variables were assessed by PSG. Cognitive performance was evaluated using the Wechsler Intelligence Scale for Children (WISC), and the final average grade of the last school year was used as a measure of academic performance. Academic performance was predicted by the following sleep variables: Sleep time, time in bed, night awakenings, and daytime sleepiness. The best predictors of cognitive performance in children with ADHD were rapid eye movement latency, light sleep, periodic limb movements index (PLMs), awakenings, and daytime sleepiness. In conclusion, sleep parameters are closely associated with the academic and cognitive functioning of children with ADHD.

A Phase 3, Placebo-Controlled Trial of Once-Daily Viloxazine Extended-Release Capsules in Adolescents With Attention-Deficit/Hyperactivity Disorder

PURPOSE

This phase 3 clinical trial evaluated the efficacy and safety of viloxazine extended-release capsules (VLX-ER) as a monotherapy for attention-deficit/hyperactivity disorder (ADHD) in adolescents (12-17 years).

METHODS

Eligible subjects (n = 310) were randomized to receive once-daily 200 and 400 mg VLX-ER, or placebo for 6 weeks. The primary efficacy end point was change from baseline (CFB) at the end of study (EOS) in ADHD Rating Scale-5 Total score. Key secondary end points were Clinical Global Impression-Improvement score at EOS, CFB at EOS in Conners 3-Parent Short Form Composite T-score, and CFB at EOS in Weiss Functional Impairment Rating Scale-Parent Total average score.

RESULTS

In the 200-mg/d and 400-mg/d VLX-ER treatment groups, a significant improvement was found in the CFB at EOS in ADHD Rating Scale-5 Total (P = 0.0232, P = 0.0091) and Inattention (P = 0.0424, P = 0.0390) and Hyperactivity/Impulsivity (P = 0.0069, P = 0.0005) subscale scores versus placebo. The Clinical Global Impression-Improvement score was significantly improved at EOS in the 200-mg/d and 400-mg/d VLX-ER groups versus placebo (P = 0.0042, P = 0.0003). The Conners 3-Parent Short Form composite T-score and Weiss Functional Impairment Rating Scale-Parent Total average score exhibited improvement in both VLX-ER groups; however, the difference versus placebo was not statistically significant. The most common treatment-related adverse events were somnolence, headache, decreased appetite, nausea, and fatigue. The adverse event-related discontinuation rates were <5% in all groups.

CONCLUSIONS

Viloxazine extended-release demonstrated statistically significant and clinically meaningful improvement in ADHD symptoms in adolescents and was generally well tolerated.

Executive Function Outcome of Treatment with Viloxazine Extended-Release Capsules in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: A Post-Hoc Analysis of Four Randomized Clinical Trials

AIM

The aim of this study was to evaluate the effect of viloxazine extended-release capsules (viloxazine ER; Qelbree™) on executive function deficits (EFDs) in pediatric subjects (6-17 years of age) with attention-deficit/hyperactivity disorder (ADHD).

METHODS

Data from four phase III placebo-controlled trials of 100-600 mg/day viloxazine ER (6-8 weeks of treatment) were used to evaluate the change from baseline (CFB) in the Conners 3rd Edition Parent Short Form-Executive Function (C3PS-EF) content scale T-score. Subjects were defined as EFD responders if they had C3PS-EF T-score > 70 at baseline and < 65 at end of study. ADHD symptoms were assessed with ADHD Rating Scale 5th Edition (ADHD-RS-5). Subjects were defined as ADHD symptom responders if they had a ≥ 50% reduction in CFB ADHD-RS-5 Total score at Week 6. The number needed to treat (NNT) and Cohen's d effect sizes were estimated for EFD and ADHD symptoms.

RESULTS

A total of 1154 subjects were included in the analysis. Statistically significant improvements in EFDs were observed with viloxazine ER versus placebo (p = 0.0002). There were 52.5% of EFD or ADHD symptom responders in the viloxazine ER treatment group and 35.4% in the placebo group (p < 0.0001). The NNT was 5.8. The Cohen's d effect size for EFD and ADHD symptoms was 0.31.

CONCLUSION

Consistent with the efficacy of viloxazine ER demonstrated in pivotal trials, viloxazine ER significantly reduced EFDs in subjects with ADHD. Moreover, a substantial proportion of subjects treated with viloxazine ER had large improvements in EFDs, ADHD symptoms, or both.

CLINICAL TRIAL REGISTRATION NUMBERS

NCT03247530, NCT03247517, NCT03247543, NCT03247556.

Qualification for upper secondary education in individuals with autism without intellectual disability: Total population study, Stockholm, Sweden

This study used the Stockholm Youth Cohort, a total population cohort (N = 364,957), to describe patterns and predictors of qualification for upper secondary education, defined by passing graduation grades in core compulsory school subjects in contemporary young individuals diagnosed with autism spectrum disorders without intellectual disability (n = 6138). At the expected age for graduation, 16 years, 29% (adjusted rate difference 95% confidence interval (28.0–30.0)) fewer autistic than non-autistic individuals were qualified for upper secondary education (57% and 86%, respectively). Comorbid attention-deficit hyperactivity disorder further increased this difference. Within the group of autistic students without intellectual disability, female sex and lower family income were associated with non-qualification for upper secondary education. The proportion of students with autism without intellectual disability who qualified for upper secondary education increased at age 20. These findings underline the need for improved support for students with a diagnosis of autism without intellectual disability in mainstream education.

Methylphenidate-Related Improvements in Math Performance Cannot Be Explained by Better Cognitive Functioning or Higher Academic Motivation: Evidence From a Randomized Controlled Trial

Objective: This study investigated whether improvements in working memory, reaction time, lapses of attention, interference control, academic motivation, and perceived competence mediated effects of methylphenidate on math performance. Method: Sixty-three children (ADHD diagnosis; methylphenidate treatment; age 8-13; IQ > 70) were randomly allocated to a 7-day methylphenidate or placebo treatment in this double-blind placebo-controlled crossover study and compared with 67 controls. Data were collected at schools and analyzed using mixed-model analysis. Methylphenidate was hypothesized to improve all measures; all measures were evaluated as potential mediators of methylphenidate-related math improvements. Results: Controls mostly outperformed the ADHD group. Methylphenidate did not affect measures of cognitive functioning (p = .082-.641) or academic motivation (p = .199-.865). Methylphenidate improved parent ratings of their child's self-perceived competence (p < .01), which mediated methylphenidate efficacy on math productivity. Conclusion: These results question the necessity of improvements in specific cognitive and motivational deficits associated with ADHD for medication-related academic improvement. They also stimulate further study of perceived competence as a mediator.

Autistic and Attention Deficit/Hyperactivity Disorder Traits Are Associated with Suboptimal Performance among Japanese University Students

Introduction:

Recent estimates suggest that there is a substantial number of Japanese students with developmental disabilities. This study aimed to examine potential associations between autistic, autistic subcomponents, and attention deficit/hyperactivity disorder (ADHD) traits with student performance (as measured by presenteeism) and class attendance among Japanese university students.

Methods:

Participants comprised 721 students from different regions of Japan who completed a self-administered internet survey. Autistic and ADHD traits were measured using an abridged version of the autism spectrum quotient (AQ-Short) and adult ADHD self-report scale (ASRS). Presenteeism, which is an indicator of student performance, was assessed using the modified World Health Organization Health and Work Performance Questionnaire. Class attendance during the past year was self-reported by participants.

Results:

Students with high levels of autistic traits and high levels of ADHD traits were significantly more likely to report poor student performance (odds ratio [OR] = 3.07, 95% confidence interval [95% CI]: 1.90–4.96; and OR = 2.13, 95% CI: 1.32–3.42, respectively). Regarding autistic trait subcomponents, students with high levels of preference for routine (OR = 2.39, 95% CI: 1.38–4.13) and high levels of difficulties with social skills (OR = 1.81, 95% CI: 1.03–3.18) were also significantly more likely to report poor student performance. There were borderline significant associations between traits of attention-switching difficulties and poor student performance (OR = 1.78, 95% CI: 1.00–3.15). Regarding ADHD trait subcomponents, students with high levels of inattention (OR = 2.88, 95% CI: 1.32–6.26) were also significantly more likely to report poor student performance. Students with both high levels of autistic traits and high levels of ADHD traits were more likely to report poor student performance than those with high levels of only one trait type. There were, however, no statistically significant associations between these traits and low class attendance risk.

Conclusions:

Sickness presenteeism was significantly associated with high levels of both autistic traits and ADHD traits among Japanese university students.

Identification of Genetic Loci Shared Between Attention-Deficit/Hyperactivity Disorder, Intelligence, and Educational Attainment

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that is consistently associated with lower levels of educational attainment. A recent large genome-wide association study identified common gene variants associated with ADHD, but most of the genetic architecture remains unknown.

METHODS

We analyzed independent genome-wide association study summary statistics for ADHD (19,099 cases and 34,194 controls), educational attainment (N = 842,499), and general intelligence (N = 269,867) using a conditional/conjunctional false discovery rate (FDR) statistical framework that increases power of discovery by conditioning the FDR on overlapping associations. The genetic variants identified were characterized in terms of function, expression, and biological processes.

RESULTS

We identified 58 linkage disequilibrium-independent ADHD-associated loci (conditional FDR < 0.01), of which 30 were shared between ADHD and educational attainment or general intelligence (conjunctional FDR < 0.01) and 46 were novel risk loci for ADHD.

CONCLUSIONS

These results expand on previous genetic and epidemiological studies and support the hypothesis of a shared genetic basis between these phenotypes. Although the clinical utility of the identified loci remains to be determined, they can be used as resources to guide future studies aiming to disentangle the complex etiologies of ADHD, educational attainment, and general intelligence.

Symptom scores and medication treatment patterns in children with ADHD versus autism

Most children with autism have ADHD, and children with ADHD-Combined and children with autism have high rates of irritable, oppositional, and aggressive behavior. Despite similar symptoms, prescribing practices may differ between autism and ADHD, which has not been examined in a single study. 1407 children with autism and 1036 with ADHD without autism, 2-17 years, were compared with 186 typical peers. Symptom scores were maternal Pediatric Behavior Scale ratings in eight areas (ADHD, oppositional/aggressive, irritable/angry, anxious, depressed, and social, writing, and learning problems). Psychotropics were prescribed to 38.0% with ADHD-Combined, 33.3% with autism, and 20.2% with ADHD-Inattentive, most often an ADHD medication (22.1% stimulant, 2.3% atomoxetine), antipsychotic (7.8%), SSRI (5.5%), and alpha agonist (4.9%). ADHD medications were more often prescribed than other medications in all diagnostic groups. Compared to autism, children with ADHD-Combined were more likely to be prescribed an ADHD medication, whereas antipsychotics and SSRIs were more likely to be prescribed in autism than in ADHD-Combined. Children with ADHD-Inattentive were least impaired and least likely to be medicated. More severely impaired children were more often medicated regardless of diagnosis. Symptom scores were far worse for treated and untreated children with ADHD and with autism than for typical peers.

Quality of life, adjustment, and associative comorbid conditions in children diagnosed with attention deficit hyperactivity disorder: A comparative study

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is a common pediatric, neurodevelopmental disorder, with serious impacts on lives of those suffering from it. ADHD is known to be associated with social and emotional difficulties, poor self-regulation, aggression, reduced empathy, inability to regulate socially desirable behavior along with conflicts within family, and increased conflict with peers and several associated comorbid conditions.

AIM

The study aims at exploring quality of life (QOL) and adjustment along with associated comorbid conditions in children diagnosed with ADHD in comparison with normal children.

METHODS

A total sample of 60 children including 30 children diagnosed with ADHD and 30 normal children were selected and assessed using Vanderbilt ADHD Parent rating scale Childhood Psychopathology Measurement Schedule, KINDL QOL: Parent Questionnaire and Pre-Adolescent adjustment Scale to assess level of ADHD, comorbid psychopathologies, their QOL and adjustment respectively.

RESULTS

Overall results have indicated that parents reported lesser symptom and pathology in comparisons to teachers for ADHD. Those diagnosed with ADHD had positive and significant comorbidities associated of; low intelligence with behavioral problems and high levels of conduct problems, anxiety, depression, psychotic tendencies, physical illness with emotional problems and somatization in comparison to normal and thus a poor adjusted life, with significant report of poor self-esteem and peer relations and QOL.

CONCLUSION

The results of the present study has clearly stated that severe burden has been perceived by ADHD children, with a poor perceived QOL, several adjustment issues, and sufferance of one or other comorbidity. Thus, the study could help understand and emphasize the need of holistic treatment comprising medicinal and therapeutic methods, including intervention for parents, focusing exclusively on enhancing and curbing these factors.

Attention-Deficit/Hyperactivity Disorder, School Performance, and Effect of Medication

OBJECTIVE

Individuals with attention-deficit/hyperactivity disorder (ADHD) are at increased risk for poor school performance, and pharmacological treatment of ADHD may have beneficial effects on school performance. Conclusions from previous research have been limited by small sample sizes, outcome measures, and treatment follow-up. The current study analyzed school performance in students with ADHD compared to students without ADHD, and the association between pharmacological treatment of ADHD and school performance.

METHOD

A linkage of Swedish national registers covering 657,720 students graduating from year 9 of compulsory school provided measures of school performance, electronically recorded dispensations of ADHD medication, and potentially confounding background factors such as parental socioeconomic status. Primary measures of school performance included student eligibility to upper secondary school and grade point sum.

RESULTS

ADHD was associated with substantially lower school performance independent of socioeconomic background factors. Treatment with ADHD medication for 3 months was positively associated with all primary outcomes, including a decreased risk of no eligibility to upper secondary school, odds ratio = 0.80, 95% confidence interval (CI) = 0.76-0.84, and a higher grade point sum (range, 0.0-320.0) of 9.35 points, 95% CI = 7.88-10.82; standardized coefficient = 0.20.

CONCLUSION

ADHD has a substantial negative impact on school performance, whereas pharmacological treatment for ADHD is associated with higher levels in several measures of school performance. Our findings emphasize the importance of detection and treatment of ADHD at an early stage to reduce the negative impact on school performance.

Editorial: Does an Attention-Deficit/Hyperactivity Disorder Pill a Day Keep Failing Grades Away?

Numerous studies have found that attention-deficit/hyperactivity disorder (ADHD) significantly impairs academic functioning. Observed impairments span diverse outcomes, from grade point average (GPA) and standardized test scores to grade retention and dropout. The impact of treating ADHD on academic functioning has received appreciable attention but remains a topic of debate because of the mixed and somewhat underwhelming results to date. The best evidence for effect is the capacity of central nervous system (CNS) stimulants to decrease problematic behaviors in the classroom.¹ However, it is not clear whether improved behavior translates into better academic functioning. In fact, there is evidence that parents might be less likely to follow through on behavioral interventions after medication has been initiated, even when parents report persistent impairment from ADHD.².

How do stimulant treatments for ADHD work? Evidence for mediation by improved cognition

BACKGROUND

Stimulant medications such as methylphenidate (MPH) are the frontline treatment for Attention-Deficit/Hyperactivity Disorder (ADHD). Despite their well-documented efficacy, the mechanisms by which stimulants improve clinical outcomes are not clear. The current study evaluated whether MPH effects on classroom behavior were mediated by improved cognitive functioning.

METHODS

Children with ADHD (n = 82; 9-12 years old) participated in a week-long summer research camp, consisting of cognitive testing, classroom periods, and recreational activities. After a baseline day, participants completed a 3-day randomized, double-blind, placebo-controlled trial of MPH (at doses approximating 0.3 and 0.6 mg/kg of immediate-release MPH dosed TID). Cognitive domains included inhibitory control (Stop Signal Task and prepulse inhibition of startle), attention (Continuous Performance Task and reaction time variability), and working memory (forward and backward spatial span). Clinical outcomes included math seatwork productivity and teacher-rated classroom behavior. A within-subjects path-analytic approach was used to test mediation. MPH-placebo and dose-response contrasts were used to evaluate drug effects.

RESULTS

Methylphenidate improved seatwork productivity and teacher ratings (ds = 1.4 and 1.1) and all domains of cognition (ds = 0.3-1.1). Inhibitory control (Stop Signal Task, SST) and working memory backward uniquely mediated the effect of MPH (vs. placebo) on productivity. Only working memory backward mediated the impact of MPH on teacher-rated behavior. The dose-response (0.6 vs. 0.3 mg/kg) effects were more modest for clinical outcomes (ds = 0.4 and 0.2) and cognition (ds = 0-0.3); there was no evidence of cognitive mediation of the clinical dose-response effects.

CONCLUSIONS

These findings are novel in demonstrating that specific cognitive processes mediate clinical improvement with stimulant treatment for ADHD. They converge with work on ADHD theory, neurobiology, and treatment development in suggesting that inhibitory control and working memory may be mechanisms of stimulant treatment response in ADHD. More work is necessary to evaluate the degree to which these findings generalize to chronic treatment, a broader array of clinical outcomes, and nonstimulant treatments.

Medical treatment of Attention Deficit/Hyperactivity Disorder (ADHD) and children's academic performance

Attention Deficit/Hyperactivity Disorder (ADHD) is negatively associated with a range of academic achievement measures. We use Danish administrative register data to study the impact of medical treatment of ADHD on children's academic performance assessed by student grade point average (GPA). Using administrative register data on children, who begin medical treatment, we conduct a natural experiment and exploit plausible exogenous variation in medical nonresponse to estimate the effect of medical treatment on school-leaving GPA. We find significant effects of treatment on both exam and teacher evaluated GPAs: Compared to consistent treatment, part or full discontinuation of treatment has large significant negative effects reducing teacher evaluation and exam GPA with .18 and .22 standard deviations, respectively. The results demonstrate that medical treatment may mitigate the negative social consequences of ADHD. Placebo regressions indicate that a causal interpretation of our findings is plausible.

Comparison of aural rehabilitation outcomes in presence and absence of back ground noise in hearing impaired children with and without attention deficit hyperactivity disorder (ADHD)

OBJECTIVE

We sought to understand the extend of improvement in seven major skills to determine the best rehabilitation approach in hearing impaired young children with and without attention deficit and hyperactivity disorder (ADHD).

METHODS

Newsha developmental scale was assessed in 40 hearing impaired children with and without ADHD in two conditions, in which seven major skills (hearing, speech, receptive language, expressive language, cognition, social communication, and motor skills) were evaluated. Two separate analyses were conducted, each after six months of rehabilitation. The first six months rehabilitation was done by controlling background noise level, while the other six months rehabilitation was performed with background multi talker babble noise, and ADHD and non ADHD children performance were compared.

RESULTS

After the first six months of rehabilitation there were no significant difference in improvement in any of the major skills except for motor and cognition skills between hearing impaired ADHD and non ADHD children. After the second six months of rehabilitation the extend of improvement was equal in both groups.

CONCLUSION

The equal improvement of hearing impaired ADHD and non- Children with ADHD support the benefits of rehabilitation program in both groups. In addition, it seems background multi talker babble noise can facilitate the process of rehabilitation in ADHD group. As a result, it is important to understand the specific needs of hearing impaired children with ADHD in rehabilitation program to provide the best services and increase the chance for success.

Association Between Medication Use and Performance on Higher Education Entrance Tests in Individuals With Attention-Deficit/Hyperactivity Disorder

IMPORTANCE

Individuals with attention-deficit/hyperactivity disorder (ADHD) are at greater risk for academic problems. Pharmacologic treatment is effective in reducing the core symptoms of ADHD, but it is unclear whether it helps to improve academic outcomes.

OBJECTIVE

To investigate the association between the use of ADHD medication and performance on higher education entrance tests in individuals with ADHD.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study observed 61 640 individuals with a diagnosis of ADHD from January 1, 2006, to December 31, 2013. Records of their pharmacologic treatment were extracted from Swedish national registers along with data from the Swedish Scholastic Aptitude Test. Using a within-patient design, test scores when patients were taking medication for ADHD were compared with scores when they were not taking such medication. Data analysis was performed from November 24, 2015, to November 4, 2016.

EXPOSURES

Periods with and without ADHD medication use.

MAIN OUTCOMES AND MEASURES

Scores from the higher education entrance examination (score range, 1-200 points).

RESULTS

Among 930 individuals (493 males and 437 females; mean [SD] age, 22.2 [3.2] years) who had taken multiple entrance tests (n = 2524) and used ADHD medications intermittently, the test scores were a mean of 4.80 points higher (95% CI, 2.26-7.34; P < .001) during periods they were taking medication vs nonmedicated periods, after adjusting for age and practice effects. Similar associations between ADHD medication use and test scores were detected in sensitivity analyses.

CONCLUSIONS AND RELEVANCE

Individuals with ADHD had higher scores on the higher education entrance tests during periods they were taking ADHD medication vs nonmedicated periods. These findings suggest that ADHD medications may help ameliorate educationally relevant outcomes in individuals with ADHD.

Contribution of Clinical Neuroimaging to the Understanding of the Pharmacology of Methylphenidate

Methylphenidate (MPH) is currently the most widely used molecule in the pharmacologic treatment of attention-deficit hyperactivity disorder (ADHD). Although experience of its application now extends over several decades, its psychotropic nature, prolonged use in children, and chemical relation to amphetamines still raise doubts in the minds of prescribers and the families of the patients. Brain imaging has shed considerable light on the neuropharmacology of MPH. The two main in vivo neuroimaging techniques are positron-emission tomography (PET) and magnetic resonance imaging (MRI), and these can be applied in both animal models and humans. The present review seeks to show how human molecular and functional imaging has contributed to determining not only the molecular targets of MPH, and the action kinetics of the various pharmaceutical forms available, but also the connectivity and brain networks activated by treatment. We also discuss the perspectives opened up by new hybrid PET-MRI techniques that enable multimodal tracking of the impact of methylphenidate on neurotransmission.

Short-Term Effects of Methylphenidate on Math Productivity in Children With Attention-Deficit/Hyperactivity Disorder are Mediated by Symptom Improvements: Evidence From a Placebo-Controlled Trial

BACKGROUND

Although numerous studies report positive effects of methylphenidate on academic performance, the mechanism behind these improvements remains unclear. This study investigates the effects of methylphenidate on academic performance in children with attention-deficit/hyperactivity disorder (ADHD) and the mediating and moderating influence of ADHD severity, academic performance, and ADHD symptom improvement.

METHODS

Sixty-three children with ADHD participated in a double-blind placebo-controlled crossover study comparing the effects of long-acting methylphenidate and placebo. Dependent variables were math, reading, and spelling performance. The ADHD group performance was compared with a group of 67 typically developing children.

RESULTS

Methylphenidate improved math productivity and accuracy in children with ADHD. The effect of methylphenidate on math productivity was partly explained by parent-rated symptom improvement, with greater efficacy for children showing more symptom improvement. Further, children showing below-average math performance while on placebo profited more from methylphenidate than children showing above-average math performance.

CONCLUSIONS

The results from this study indicate positive effects of methylphenidate on academic performance, although these were limited to math abilities. In light of these results, expectations of parents, teachers, and treating physicians about the immediate effects of methylphenidate on academic improvement should be tempered. Moreover, our results implicate that positive effects of methylphenidate on math performance are in part due directly to effects on math ability and in part due to reductions in ADHD symptoms.

Combined Modality Intervention for ADHD With Comorbid Reading Disorders: A Proof of Concept Study

To evaluate the relative efficacy of two reading programs with and without adjunctive stimulant medication for children with attention-deficit/hyperactivity disorder and comorbid reading disorder (ADHD+RD). Sixty-five children (7-11 years in age) were assigned randomly to one of three intensive remedial academic programs (phonologically or strategy-based reading instruction, or general academic strategy and social skills training) in combination with either immediate-release methylphenidate or placebo. Multiple-blind procedures were used for medication/placebo, given twice daily. Children received 35 hours of instruction in 10 weeks, taught by a trained teacher in a separate school classroom, in small matched groups of 2 to 3. Children's behavior and reading abilities were assessed before and after intervention. Stimulant medication produced expected beneficial effects on hyperactive/impulsive behavioral symptoms (reported by classroom teachers) but none on reading. Children receiving a reading program showed greater gains than controls on multiple standardized measures of reading and related skills (regardless of medication status). Small sample sizes precluded interpretation of possible potentiating effects of stimulant medication on reading skills taught in particular reading programs. Intensive reading instruction, regardless of treatment with stimulant medication, may be efficacious in improving reading problems in children with ADHD+RD and warrants further investigation in a large-scale study.