Methylphenidate improves reading performance in children with attention deficit hyperactivity disorder and comorbid dyslexia: an unblinded clinical trial

Society for Developmental and Behavioral Pediatrics Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is the most common childhood neurodevelopmental disorder and is associated with an array of coexisting conditions that complicate diagnostic assessment and treatment. ADHD and its coexisting conditions may impact function across multiple settings (home, school, peers, community), placing the affected child or adolescent at risk for adverse health and psychosocial outcomes in adulthood. Current practice guidelines focus on the treatment of ADHD in the primary care setting. The Society for Developmental and Behavioral Pediatrics has developed this practice guideline to facilitate integrated, interprofessional assessment and treatment of children and adolescents with "complex ADHD" defined by age (<4 years or presentation at age >12 years), presence of coexisting conditions, moderate to severe functional impairment, diagnostic uncertainty, or inadequate response to treatment.

Sensory white noise improves reading skills and memory recall in children with reading disability

BACKGROUND

Reading disability (RD) is characterized by slow and inaccurate word reading development, commonly reflecting underlying phonological problems. We have previously shown that exposure to white noise acutely improves cognitive performance in children with ADHD. The question addressed here is whether white noise exposure yields positive outcomes also for RD. There are theoretical reasons to expect such a possibility: a) RD and ADHD are two overlapping neurodevelopmental disorders and b) since prior research on white noise benefits has suggested that a central mechanism might be the phenomenon of stochastic resonance, then adding certain kinds of white noise might strengthen the signal-to-noise ratio during phonological processing and phoneme-grapheme mapping.

METHODS

The study was conducted with a group of 30 children with RD and phonological decoding difficulties and two comparison groups: one consisting of skilled readers (n = 22) and another of children with mild orthographic reading problems and age adequate phonological decoding (n = 30). White noise was presented experimentally in visual and auditory modalities, while the children performed tests of single word reading, orthographic word recognition, nonword reading, and memory recall.

RESULTS

For the first time, we show that visual and auditory white noise exposure improves some reading and memory capacities "on the fly" in children with RD and phonological decoding difficulties. By contrast, the comparison groups displayed either no benefit or a gradual decrease in performance with increasing noise. In interviews, we also found that the white noise exposure was tolerable or even preferred by many children.

CONCLUSION

These novel findings suggest that poor readers with phonological decoding difficulties may be immediately helped by white noise during reading. Future research is needed to determine the robustness, mechanisms, and long-term practical implications of the white noise benefits in children with reading disabilities.

The Effects of ADHD Treatment and Reading Intervention on the Fluency and Comprehension of Children with ADHD and Word Reading Difficulties: A Randomized Clinical Trial

Many students with reading difficulties and disabilities (RD) also have Attention Deficit/Hyperactivity Disorder (ADHD). This randomized clinical trial compared the effects of ADHD treatment alone (medication, parent training), intensive reading intervention alone, and their combination on the reading fluency and comprehension of students with both disorders. Students with ADHD and RD were randomly assigned to receive (a) Reading Intervention only (n=74), (b) ADHD Treatment only (n=78), or (c) simultaneous Combined ADHD and RD Treatment (n=70). For phonemic decoding fluency, the Reading Intervention group and the Combined Treatment group both had significantly better outcomes than the ADHD Treatment group, but did not differ from one another. For passage comprehension, the ADHD Treatment group had significantly better outcomes than the Reading Intervention group, while the other groups did not differ from one another. ADHD treatment may support passage comprehension in this population, while fluent decoding is best supported through intensive reading intervention.

Using ADHD Medications to Treat Coexisting ADHD and Reading Disorders: A Systematic Review

Attention-deficit/hyperactivity disorder (ADHD), the most common pediatric neurobehavioral disorder, frequently presents with coexisting reading disorders (RDs). Despite this, it is unclear whether medication improves symptoms and function in children with comorbid ADHD and RD. We present a systematic review of studies investigating the effects of ADHD medications on ADHD symptoms, academic outcomes, and neuropsychological measures in this important group.

Methylphenidate for attention deficit hyperactivity disorder (ADHD) in children and adolescents - assessment of adverse events in non-randomised studies

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder in childhood. The psychostimulant methylphenidate is the most frequently used medication to treat it. Several studies have investigated the benefits of methylphenidate, showing possible favourable effects on ADHD symptoms, but the true magnitude of the effect is unknown. Concerning adverse events associated with the treatment, our systematic review of randomised clinical trials (RCTs) demonstrated no increase in serious adverse events, but a high proportion of participants suffered a range of non-serious adverse events.

OBJECTIVES

To assess the adverse events associated with methylphenidate treatment for children and adolescents with ADHD in non-randomised studies.

SEARCH METHODS

In January 2016, we searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, 12 other databases and two trials registers. We also checked reference lists and contacted authors and pharmaceutical companies to identify additional studies.

SELECTION CRITERIA

We included non-randomised study designs. These comprised comparative and non-comparative cohort studies, patient-control studies, patient reports/series and cross-sectional studies of methylphenidate administered at any dosage or formulation. We also included methylphenidate groups from RCTs assessing methylphenidate versus other interventions for ADHD as well as data from follow-up periods in RCTs. Participants had to have an ADHD diagnosis (from the 3rd to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders or the 9th or 10th edition of theInternational Classification of Diseases, with or without comorbid diagnoses. We required that at least 75% of participants had a normal intellectual capacity (intelligence quotient of more than 70 points) and were aged below 20 years. We excluded studies that used another ADHD drug as a co-intervention.

DATA COLLECTION AND ANALYSIS

Fourteen review authors selected studies independently. Two review authors assessed risk of bias independently using the ROBINS-I tool for assessing risk of bias in non-randomised studies of interventions. All review authors extracted data. We defined serious adverse events according to the International Committee of Harmonization as any lethal, life-threatening or life-changing event. We considered all other adverse events to be non-serious adverse events and conducted meta-analyses of data from comparative studies. We calculated meta-analytic estimates of prevalence from non-comparative cohorts studies and synthesised data from patient reports/series qualitatively. We investigated heterogeneity by conducting subgroup analyses, and we also conducted sensitivity analyses.

MAIN RESULTS

We included a total of 260 studies: 7 comparative cohort studies, 6 of which compared 968 patients who were exposed to methylphenidate to 166 controls, and 1 which assessed 1224 patients that were exposed or not exposed to methylphenidate during different time periods; 4 patient-control studies (53,192 exposed to methylphenidate and 19,906 controls); 177 non-comparative cohort studies (2,207,751 participants); 2 cross-sectional studies (96 participants) and 70 patient reports/series (206 participants). Participants' ages ranged from 3 years to 20 years. Risk of bias in the included comparative studies ranged from moderate to critical, with most studies showing critical risk of bias. We evaluated all non-comparative studies at critical risk of bias. The GRADE quality rating of the evidence was very low.Primary outcomesIn the comparative studies, methylphenidate increased the risk ratio (RR) of serious adverse events (RR 1.36, 95% confidence interval (CI) 1.17 to 1.57; 2 studies, 72,005 participants); any psychotic disorder (RR 1.36, 95% CI 1.17 to 1.57; 1 study, 71,771 participants); and arrhythmia (RR 1.61, 95% CI 1.48 to 1.74; 1 study, 1224 participants) compared to no intervention.In the non-comparative cohort studies, the proportion of participants on methylphenidate experiencing any serious adverse event was 1.20% (95% CI 0.70% to 2.00%; 50 studies, 162,422 participants). Withdrawal from methylphenidate due to any serious adverse events occurred in 1.20% (95% CI 0.60% to 2.30%; 7 studies, 1173 participants) and adverse events of unknown severity led to withdrawal in 7.30% of participants (95% CI 5.30% to 10.0%; 22 studies, 3708 participants).Secondary outcomesIn the comparative studies, methylphenidate, compared to no intervention, increased the RR of insomnia and sleep problems (RR 2.58, 95% CI 1.24 to 5.34; 3 studies, 425 participants) and decreased appetite (RR 15.06, 95% CI 2.12 to 106.83; 1 study, 335 participants).With non-comparative cohort studies, the proportion of participants on methylphenidate with any non-serious adverse events was 51.2% (95% CI 41.2% to 61.1%; 49 studies, 13,978 participants). These included difficulty falling asleep, 17.9% (95% CI 14.7% to 21.6%; 82 studies, 11,507 participants); headache, 14.4% (95% CI 11.3% to 18.3%; 90 studies, 13,469 participants); abdominal pain, 10.7% (95% CI 8.60% to 13.3%; 79 studies, 11,750 participants); and decreased appetite, 31.1% (95% CI 26.5% to 36.2%; 84 studies, 11,594 participants). Withdrawal of methylphenidate due to non-serious adverse events occurred in 6.20% (95% CI 4.80% to 7.90%; 37 studies, 7142 participants), and 16.2% were withdrawn for unknown reasons (95% CI 13.0% to 19.9%; 57 studies, 8340 participants).

AUTHORS' CONCLUSIONS

Our findings suggest that methylphenidate may be associated with a number of serious adverse events as well as a large number of non-serious adverse events in children and adolescents, which often lead to withdrawal of methylphenidate. Our certainty in the evidence is very low, and accordingly, it is not possible to accurately estimate the actual risk of adverse events. It might be higher than reported here.Given the possible association between methylphenidate and the adverse events identified, it may be important to identify people who are most susceptible to adverse events. To do this we must undertake large-scale, high-quality RCTs, along with studies aimed at identifying responders and non-responders.

Study of the effect of Memantine therapy on the treatment of dyslexia in children

Background

Reading disorder (RD) is one of the important complaints in children with learning disorders (LD) that is prevalent in 4% of children in the United States. Treating this disorder includes education of reading practices and treating psychological disorders, and there are no exact medications prescribed in these children. Memantine has been effective in treating memory problems in Alzheimer Dementia, obsessive-compulsive disorder, autism disorder, and other psychological diseases. The aim of this study is to evaluate the effect of memantine in improving RD in children.

Materials and Methods

In this randomized clinical trial, 62 children, with RD in Pediatric Psychiatry Clinics of Noor and Ali-Asghar Hospital in Isfahan from 2015 to 2016, were participated. They were randomly assigned to two groups of equal number, one receiving education plus memantine and the other education plus placebo. RD was evaluated at the beginning, 1 and 3 months after intervention by Iranian standard reading and dyslexia test (Nama).

Results

Mean (standard deviation) age of participants was 7.55 (0.60) years. Most of the participants were boy (55%), most having parents in 36-45-year-old age group (52% and 48% for fathers and mothers, respectively), and also most parents in diploma and bachelor educational group (61% and 60% for fathers and mothers, respectively). There were statistical significant difference in trend of total score (P = 0.034), word chain (P < 0.001), rhyming (P < 0.001), text comprehension (P < 0.001), and letter fluency (P = 0.002), subscale between two groups. However, the difference of time trend between two groups was not significant in word reading (P = 0.14), word comprehension (P = 0.06), phoneme deletion (P = 0.12), reading nonwords (P = 0.32), and category fluency (P = 0.06).

Conclusion

Adding memantine to educational practices is effective in improving RD in school-age children with LD.

Comparing treatments for children with ADHD and word reading difficulties: A randomized clinical trial

OBJECTIVE

This trial compared attention-deficit/hyperactivity disorder (ADHD) treatment alone, intensive reading intervention alone, and their combination for children with ADHD and word reading difficulties and disabilities (RD).

METHOD

Children (n = 216; predominantly African American males) in Grades 2-5 with ADHD and word reading/decoding deficits were randomized to ADHD treatment (medication + parent training), reading treatment (reading instruction), or combined ADHD + reading treatment. Outcomes were parent and teacher ADHD ratings and measures of word reading/decoding. Analyses utilized a mixed models covariate-adjusted gain score approach with posttest regressed onto pretest.

RESULTS

Inattention and hyperactivity/impulsivity outcomes were significantly better in the ADHD (parent Hedges's g = .87/.75; teacher g = .67/.50) and combined (parent g = 1.06/.95; teacher g = .36/41) treatment groups than reading treatment alone; the ADHD and Combined groups did not differ significantly (parent g = .19/.20; teacher g = .31/.09). Word reading and decoding outcomes were significantly better in the reading (word reading g = .23; decoding g = .39) and combined (word reading g = .32; decoding g = .39) treatment groups than ADHD treatment alone; reading and combined groups did not differ (word reading g = .09; decoding g = .00). Significant group differences were maintained at the 3- to 5-month follow-up on all outcomes except word reading.

CONCLUSIONS

Children with ADHD and RD benefit from specific treatment of each disorder. ADHD treatment is associated with more improvement in ADHD symptoms than RD treatment, and reading instruction is associated with better word reading and decoding outcomes than ADHD treatment. The additive value of combining treatments was not significant within disorder, but the combination allows treating both disorders simultaneously. (PsycINFO Database Record

Effect of Atomoxetine Treatment on Reading and Phonological Skills in Children with Dyslexia or Attention-Deficit/Hyperactivity Disorder and Comorbid Dyslexia in a Randomized, Placebo-Controlled Trial

OBJECTIVES

Evaluated the effects of atomoxetine on the reading abilities of children with dyslexia only or attention-deficit/hyperactivity disorder (ADHD) and comorbid dyslexia.

METHODS

Children aged 10-16 years (N = 209) met Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) criteria for dyslexia only (n = 58), ADHD and comorbid dyslexia (n = 124), or ADHD only (n = 27) and were of normal intelligence. Patients were treated with atomoxetine (1.0-1.4 mg/kg/day) or placebo in a 16-week, randomized, placebo-controlled, double-blind trial. The dyslexia-only and ADHD and comorbid dyslexia groups were randomized 1:1; the ADHD-only group received atomoxetine in a blinded manner. Reading abilities were measured with the Woodcock Johnson III (WJIII), Comprehensive Test of Phonological Processing (CTOPP), Gray Oral Reading Tests-4, and Test of Word Reading Efficiency.

RESULTS

Atomoxetine-treated dyslexia-only patients compared with placebo patients had significantly greater improvement (p < 0.02) with moderate to approaching high effect sizes (ES) on WJIII Word Attack (ES = 0.72), Basic Reading Skills (ES = 0.48), and Reading Vocabulary (ES = 0.73). In the atomoxetine-treated ADHD and comorbid dyslexia group, improvement on the CTOPP Elision measure (ES = 0.50) was significantly greater compared with placebo (p < 0.02). Total, inattentive, and hyperactive/impulsive ADHD symptom reductions were significant in the atomoxetine-treated ADHD and comorbid dyslexia group compared with placebo, and from baseline in the ADHD-only group (p ≤ 0.02). ADHD symptom improvements in the ADHD and comorbid dyslexia group were not correlated with improvements in reading.

CONCLUSIONS

Atomoxetine treatment improved reading scores in patients with dyslexia only and ADHD and comorbid dyslexia. Improvements for patients with dyslexia only were in critical components of reading, including decoding and reading vocabulary. For patients with ADHD and comorbid dyslexia, improvements in reading scores were distinct from improvement in ADHD inattention symptoms alone. These data represent the first report of improvements in reading measures following pharmacotherapy treatment in patients with dyslexia only evaluated in a randomized, double-blind trial.

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.

A randomized, double-blind, cross-over, phase IV trial of oros-methylphenidate (CONCERTA(®)) and generic novo-methylphenidate ER-C (NOVO-generic)

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) is a common neurobehavioral disorder with onset during childhood. Multiple aspects of a child's development are hindered, in both home and school settings, with negative impacts on social, emotional, and cognitive functioning. If left untreated, ADHD is commonly associated with poor academic achievement and low occupational status, as well as increased risk of substance abuse and delinquency. The objective of this study was to evaluate adult ADHD subject reported outcomes when switched from a stable dose of CONCERTA(®) to the same dose of generic Novo-methylphenidate ER-C(®).

METHODS

Randomized, double-blind, cross-over, phase IV trial consisted of two phases in which participants with a primary diagnosis of ADHD were randomized in a 1:1 ratio to 3 weeks of treatment with CONCERTA or generic Novo-Methylphenidate ER-C. Following 3 weeks of treatment, participants were crossed-over to receive the other treatment for an additional 3 weeks. Primary efficacy was assessed through the use of the Treatment Satisfaction Questionnaire for Medication, Version II (TSQM-II).

RESULTS

Participants with ADHD treated with CONCERTA were more satisfied in terms of efficacy and side effects compared to those receiving an equivalent dose of generic Novo-Methylphenidate ER-C. All participants chose to continue with CONCERTA treatment at the conclusion of the study.

CONCLUSION

Although CONCERTA and generic Novo-Methylphenidate ER-C have been deemed bioequivalent, however the present findings demonstrate clinically and statistically significant differences between generic and branded CONCERTA. Further investigation of these differences is warranted.

Children with Attention Deficit/Hyperactivity Disorder and Reading Disability: A Review of the Efficacy of Medication Treatments

Reading is a multifaceted skillset that has the potential to profoundly impact a child's academic performance and achievement. Mastery of reading skills is often an area of difficulty for children during their academic journey, particularly for children with Attention Deficit/Hyperactivity Disorder (ADHD), Specific Learning Disorder with Impairment in Reading (SLD-R), or children with a comorbid diagnosis of both ADHD and SLD-R. ADHD is characterized by executive functioning and impulse control deficits, as well as inattention and impulsivity. Among the academic struggles experienced by children with ADHD are challenges with word reading, decoding, or reading comprehension. Similarly, children with SLD-R frequently encounter difficulties in the development of appropriate reading skills. SLD-R incorporates dysfunctions in basic visual and auditory processes that result in difficulties with decoding and spelling words. There have been limited empirical studies investigating the efficacy of interventions to improve the reading ability of children with both ADHD and SLD-R. Research studies that have focused on reading interventions for children from this population have predominantly included the use of medication treatments with stimulants (e.g., methylphenidate) and non-stimulants (e.g., atomoxetine). This review paper will present and integrate findings from empirical studies on successful medication treatments for children with comorbid ADHD and SLD-R. Furthermore, this paper will extend findings from empirically successful medication treatments to provide directions for future research.

The Impact of Intensive Reading Intervention on Level of Attention in Middle School Students

The purpose of the study was to estimate the impact of reading intervention on ratings of student attention over time. We used extant data from a longitudinal randomized study of a response-based reading intervention to fit a multiple-indicator, multilevel growth model. The sample at randomization was 54% male, 18% limited English proficient, 85% eligible for free or reduced-price lunch, 58% African American, and 32% Hispanic. Reading ability was measured by using the Woodcock-Johnson III Tests of Achievement. Attention was measured by using the Strengths and Weaknesses of ADHD Symptoms and Normal Behavior Scale. Findings indicate that intensive, response-based reading intervention over 3 years improved reading achievement and behavioral attention in middle school struggling readers, with treatment directly affecting reading, which in turn influenced attention. In the business-as-usual condition, there was no relation between improved reading and attention. The results are consistent with a correlated liabilities model of comorbidity. The results do not align with the inattention-as-cause hypothesis, which predicts that reading intervention should not affect attention. The findings do not support, but do not necessarily preclude, the phenocopy hypothesis. The results are especially pertinent for older students who may be inattentive partly because of years of struggling with reading.

Nonword reading and Stroop interference: what differentiates attention-deficit/hyperactivity disorder and reading disability?

BACKGROUND

Attention deficits and impaired reading performance co-occur more often than expected by chance; however, the underlying mechanism of this association still remains rather unexplored.

METHOD

In two consecutive studies, children aged 8 to 12 years with attention-deficit/hyperactivity disorder (ADHD) and children with reading disability (RD) were examined using a 2 (ADHD versus no ADHD) × 2 (RD versus no RD) factorial design. To further delineate deficient interference control from reading processes, we used a newly developed self-paced word/nonword reading task (Experiment 1, n = 68) and a modified computerized Stroop paradigm, including an orthographic phonological neighbor (OPN) condition (Experiment 2, n = 84).

RESULTS

RD (compared to non-RD groups) was associated with impairments in both word and nonword reading, while children with ADHD also showed impaired nonword reading. In the Stroop task, RD, but not ADHD, had a significant impact on task performance. Interestingly, a significant interaction between ADHD, RD, and task condition emerged, which was due to particularly slower reaction times to nonwords in children with RD only, while task performance in children with comorbid ADHD and RD resembled that of ADHD only.

CONCLUSIONS

Thus, our results demonstrate that impairments in nonword reading were not specific to RD but were also present in children with ADHD. In addition, RD and not ADHD was characterized by poor interference control in the Stroop task. These findings question whether unique cognitive deficits are specific to either ADHD or RD.

Neuroimaging markers for the prediction of treatment response to Methylphenidate in ADHD

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most prevalent mental disorders of childhood, which often continues into adulthood. Methylphenidate is one the most commonly used medication to treat ADHD, however up to 30% of patients do not respond to it.

AIMS

This paper aims to review studies, which employed neuroimaging to predict treatment response to Methylphenidate in ADHD.

METHODS

Systematic literature searches were performed using several databases. Selected articles had to describe an original study that identified neuroimaging markers for the prediction of treatment response to Methylphenidate in ADHD.

RESULTS

Eighty-three articles were found, of which twelve were selected for the present review. Several neuroimaging markers to predict response to MPH were suggested including DAT status, size of medial prefrontal cortex and corpus callosum.

CONCLUSION

Some promising findings have been identified and they should motivate additional work to establish more reliable neuroimaging markers of treatment response to MPH in ADHD.

Psychostimulant and sensory stimulation interventions that target the reading and math deficits of students with ADHD

OBJECTIVE

The purpose of this review of students with attention deficit hyperactivity disorder (ADHD) was to summarize the following: (1) academic deficits in math and reading, (2) possible theoretical contributors to these deficits, and (3) psychostimulant interventions that target math and reading, as well as, parallel interventions involving sensory stimulation.

METHOD

A comprehensive examination of the literature was conducted on children with ADHD with and without co-occurring disabilities, summarizing their reading and math achievement and the effects of psychostimulant and sensory stimulant interventions on these academic areas.

RESULTS

Students without co-occurring disabilities (ADHD-) had fewer deficits in reading than in math and than students with co-occurring disabilities (ADHD+). Furthermore, students with ADHD+ demonstrated greater responsiveness to psychostimulants through improved reading recognition and math calculations, with limited gains in literal reading comprehension. Added sensory stimulation produced differential gains for both groups in reading recognition and comprehension and in math calculations and problem solving.

CONCLUSION

The efficacy of psychostimulants was documented on specific areas of achievement for the ADHD+ group, but this review did not support the administration of psychostimulants for students with ADHD-. For both groups of students, differential gains, losses, and habituation were documented in response to sensory stimulation for both subareas within reading and math, which were interpreted as support for the optimal stimulation theory.

The co-occurrence of reading disorder and ADHD: epidemiology, treatment, psychosocial impact, and economic burden

The co-occurrence of reading disorder (RD) and attention-deficit/hyperactivity disorder (ADHD) has received increasing attention. This review summarizes the epidemiology, treatment strategies, psychosocial impact, and economic burden associated with the co-occurrence of these conditions. Common genetic and neuropsychological deficits may partially explain the high degree of overlap between RD and ADHD. Children who face the additive problems of both disorders are at greater risk for academic failure, psychosocial consequences, and poor long-term outcomes that persist into adulthood. However, few studies have evaluated interventions targeted to this patient population, underscoring the importance of identifying effective multimodal treatments that address the neuropsychological deficits of RD and ADHD through carefully planned clinical research.

Reading performance as a function of treatment with lisdexamfetamine dimesylate in elementary school children diagnosed with ADHD

BACKGROUND

Medication treatment studies of ADHD have typically not assessed effects on reading performance, although reading difficulties frequently co-occur in children with ADHD. The current study characterizes the effects of lisdexamfetamine dimesylate (LDX; Vyvanse(®), Shire US Inc.), at peak efficacy, on reading performance in children with ADHD.

METHOD

Children (ages 6-12; N = 26) with ADHD enrolled in a modified laboratory school study with an open-label, dose-optimization phase of LDX (30-70 mg/d). The Gray Oral Reading Test-4 (GORT-4) with measures of rate, accuracy, and comprehension was administered at baseline and 3-4 hr postdose, following 4 to 5 weeks of optimal dose titration.

RESULTS

Treatment reduced ADHD symptoms. Reading rate was improved, especially among children with higher verbal fluid reasoning without additional symptoms of neurodevelopmental delay. No differences were observed for reading accuracy or comprehension.

CONCLUSION

Endophenotypical profiles may predict drug effects in specific skill areas, such as reading rate.

Zusammenhang zwischen Aufmerksamkeitsdefiziten und Lese-Rechtschreibschwäche

Neben anderen Voraussetzungen sind beim Lese- und Rechtschreiberwerb Aufmerksamkeitsprozesse essentiell. In der vorliegenden Studie wurde modellorientiert erfasst, in welchen Teilkomponenten der Aufmerksamkeit Kinder mit einer Lese- Rechtschreibstörung (LRS) auffällig sind. Dazu wurden 32 Kinder mit einer LRS aus dem dritten und vierten Schuljahr mit 31 Kontrollkindern verglichen. Alle Kinder führten computergestützte Aufmerksamkeitsaufgaben durch, mit denen Intensitätsaspekte, Selektivitätsaspekte, Kontrollfunktionen und räumliche Ausrichtung der Aufmerksamkeit überprüft wurden. Es zeigte sich, dass Defizite im Lesen und Schreiben mit Leistungen im Bereich der Aufmerksamkeit korrelieren. Im Vergleich zur Kontrollgruppe konnten Defizite für Intensitätsaspekte der Aufmerksamkeit, räumliche Aufmerksamkeitsaspekte und kontrollierende Aufmerksamkeitsfunktionen festgestellt werden. Schlussfolgernd sprechen die Ergebnisse dafür, dass eine LRS mit Defiziten in der Aufmerksamkeit assoziiert ist.

Executive impairment determines ADHD medication response: implications for academic achievement

Methylphenidate (MPH) often ameliorates attention-deficit/hyperactivity disorder (ADHD) behavioral dysfunction according to indirect informant reports and rating scales. The standard of care behavioral MPH titration approach seldom includes direct neuropsychological or academic assessment data to determine treatment efficacy. Documenting "cool" executive-working memory (EWM) and "hot" self-regulation (SR) neuropsychological impairments could aid in differential diagnosis of ADHD subtypes and determining cognitive and academic MPH response. In this study, children aged 6 to 16 with ADHD inattentive type (IT; n = 19) and combined type (n = 33)/hyperactive-impulsive type (n = 4) (CT) participated in double-blind placebo-controlled MPH trials with baseline and randomized placebo, low MPH dose, and high MPH dose conditions. EWM/ SR measures and behavior ratings/classroom observations were rank ordered separately across conditions, with nonparametric randomization tests conducted to determine individual MPH response. Participants were subsequently grouped according to their level of cool EWM and hot SR circuit dysfunction. Robust cognitive and behavioral MPH response was achieved for children with significant baseline EWM/SR impairment, yet response was poor for those with adequate EWM/ SR baseline performance. Even for strong MPH responders, the best dose for neuropsychological functioning was typically lower than the best dose for behavior. Findings offer one possible explanation for why long-term academic MPH treatment gains in ADHD have not been realized. Implications for academic achievement and medication titration practices for children with behaviorally diagnosed ADHD will be discussed.

The genetic association between ADHD symptoms and reading difficulties: the role of inattentiveness and IQ

Previous studies have documented the primarily genetic aetiology for the stronger phenotypic covariance between reading disability and ADHD inattention symptoms, compared to hyperactivity-impulsivity symptoms. In this study, we examined to what extent this covariation could be attributed to “generalist genes” shared with general cognitive ability or to “specialist” genes which may specifically underlie processes linking inattention symptoms and reading difficulties. We used multivariate structural equation modeling on IQ, parent and teacher ADHD ratings and parent ratings on reading difficulties from a general population sample of 1312 twins aged 7.9–10.9 years. The covariance between reading difficulties and ADHD inattention symptoms was largely driven by genetic (45%) and child-specific environment (21%) factors not shared with IQ and hyperactivity-impulsivity; only 11% of the covariance was due to genetic effects common with IQ. Aetiological influences shared among all phenotypes explained 47% of the variance in reading difficulties. The current study, using a general population sample, extends previous findings by showing, first, that the shared genetic variability between reading difficulties and ADHD inattention symptoms is largely independent from genes contributing to general cognitive ability and, second, that child-specific environment factors, independent from IQ, also contribute to the covariation between reading difficulties and inattention symptoms.

A current update on ADHD pharmacogenomics

Pharmacological treatment for attention deficit hyperactivity disorder, although highly effective, presents a marked variability in clinical response, optimal dosage needed and tolerability. Clinical and neurobiological investigations have juxtaposed findings on both response to medication and etiologic factors, generating the hypothesis that genetic factors may underlie differences in treatment outcome. Over the last decade, research has focused on the catecholaminergic system to investigate a potential role of genotype on pharmacological effect. Despite an increasing number of associations reported (for methylphenidate, nine in 2005, 24 in 2008 and 52 reported in the current article), the identification of clinically relevant genetic predictors of treatment response remains a challenge. At present, additional studies are required to allow for a shift from a trial-and-error approach to a more rational pharmacologic regimen that takes into account the likelihood of treatment effectiveness at the individual level.

Atomoxetine for the treatment of attention-deficit/hyperactivity disorder (ADHD) in children with ADHD and dyslexia

BACKGROUND

The objective of this study was to assess the effects of atomoxetine on treating attention-deficit/hyperactivity disorder (ADHD), on reading performance, and on neurocognitive function in youth with ADHD and dyslexia (ADHD+D).

METHODS

Patients with ADHD (n = 20) or ADHD+D (n = 36), aged 10-16 years, received open-label atomoxetine for 16 weeks. Data from the ADHD Rating Scale-IV (ADHDRS-IV), Kaufman Test of Educational Achievement (K-TEA), Working Memory Test Battery for Children (WMTB-C), and Life Participation Scale for ADHD-Child Version (LPS-C) were assessed.

RESULTS

Atomoxetine demonstrated significant improvement for both groups on the ADHDRS-IV, LPS-C, and K-TEA reading comprehension standard and composite scores. K-TEA spelling subtest improvement was significant for the ADHD group, whereas the ADHD+D group showed significant reading decoding improvements. Substantial K-TEA reading and spelling subtest age equivalence gains (in months) were achieved for both groups. The WMTB-C central executive score change was significantly greater for the ADHD group. Conversely, the ADHD+D group showed significant phonological loop score enhancement by visit over the ADHD group. Atomoxetine was well tolerated, and commonly reported adverse events were similar to those previously reported.

CONCLUSIONS

Atomoxetine reduced ADHD symptoms and improved reading scores in both groups. Conversely, different patterns and magnitude of improvement in working memory component scores existed between ADHD and ADHD+D patients. Though limited by small sample size, group differences in relation to the comparable changes in improvement in ADHD symptoms could suggest that brain systems related to the therapeutic benefit of atomoxetine in reducing ADHD symptoms may be different in individuals with ADHD+D and ADHD without dyslexia.

TRIAL REGISTRATION

CLINICAL TRIAL REGISTRY

ClinicalTrials.gov: NCT00191048.

Clinical and cognitive response to extended-release methylphenidate (Medikinet) in attention deficit/hyperactivity disorder: efficacy evaluation

INTRODUCTION

The objective of the study was to assess the efficacy of extended-release methylphenidate (Mph-ER) (Medikinet; MEDICE Arzneimittel Pütter GmbH & Co KG, Iserlohn, Germany) in the pediatric population with attention deficit/hyperactivity disorder (ADHD); a parallel analysis of the validity of various tools for monitoring short-term clinical response to treatment was made.

METHODS

This was a retrospective analysis of 94 children with ADHD who received treatment with Mph-ER. The ADHD Rating Scale-IV (ADHD-RS) was used to assess clinical efficacy. The following neuropsychological tests were used to assess cognitive-attentional efficacy: the faces test, the D2 test, the Magallanes visual attention scale (EMAV; Escalas Magallanes de Attencion Visual), and the Conners' Continuous Performance Test II (CPT-II). The ADHD-RS scale was completed by the parents at the time of diagnosis and after 3 months of treatment. The tests were taken by patients both without treatment and under the effects of treatment. The results of these variables were transformed into Z values for subsequent analysis.

RESULTS

In all, 84% of the patients lowered their ADHD-RS score with Mph-ER. Regarding the neuropsychological tests, a significant change was seen when the results of patients without treatment were compared with their later results with treatment. When the order of test conditions was reversed (with and then without treatment), the CPT-II was the only test for which there was still a significant difference.

CONCLUSION

Mph-ER improved attention and self-control from a clinical and cognitive point of view. Of those studied, the CPT-II was the most effective neuropsychological test for monitoring efficacy of Mph in the short-term.

Effects of methylphenidate on working memory functioning in children with attention deficit/hyperactivity disorder

BACKGROUND AND AIMS

Children with attention deficit/hyperactivity disorder (ADHD) often show deficits in working memory performance. Methylphenidate (MPH) is an effective medication to improve these cognitive difficulties. This study aimed to clarify which effect MPH induces on the underlying functional networks of working memory.

METHODS

Fourteen boys diagnosed with ADHD and 12 healthy controls were investigated using functional magnetic resonance imaging (fMRI). Each patient was tested twice, once with medication and once without. The fMRI experiments consisted of three verbal N-back tasks with increasing difficulty. Functional images were acquired on a 3 Tesla head scanner.

RESULTS

On the behavioral level, medicated patients performed similar to healthy controls and significantly better than without medication. On the functional level, patients showed the expected frontal and parietal activations, which were more pronounced in the 2- and 3-back tasks. Healthy controls showed significantly more activation in these regions and additional activation in the cerebellum. Interestingly, patients showed an additional effect of laterality. Left-sided frontal and parietal activation in patients was significantly less pronounced than in controls.

CONCLUSION

Functional data indicate different activation patterns in verbal working memory tasks between healthy controls and patients with ADHD irrespective of medication condition. Intake of MPH led to a clear improvement on a behavioral level. However, this effect was not reflected by changes in functional brain organization. MPH-induced changes leading to better performance in verbal working memory tasks might be very subtle and therefore not detectable by fMRI.

Promoting reading in children: do reading practices differ in children with developmental problems?

OBJECTIVE

The objective of this study was to describe and compare reading practices in caregivers of children with developmental/behavioral problems (DEV) to caregivers of children without developmental problems attending a general pediatric clinic (GEN).

METHOD

Cross-sectional, convenience samples of 321 caregivers of DEV and GEN children self-report reading practices including amount of daytime and nighttime reading, TV viewing, and number of books in the house. Reading 4 or more days per week is the primary outcome. Multivariate logistic regression analysis was used to compare reading 4 or more days per week with specific predictors. Odds ratios and 95% confidence intervals were reported.

RESULTS

Three hundred and twenty-one caregivers participated in the study (DEV 204, GEN 117). Mean number of books in home (51.1+/-49.9), TV viewing hours per day (2.6+/-2.0), and days or nights read per week (days, 4.9+/-2.1; nights, 4.0+/-2.4) did not differ by group. Caregivers reporting incomes at 200% above the federal poverty level (FPL) were more likely to engage in reading more than 4 days per week (odds ratio 5.32; 95% confidence intervals, 1.19, 23.81) after controlling for developmental status, caregiver education and age, and frequency of television viewing.

CONCLUSION

Positive home reading practices were predicted by FPL in children with and without developmental or behavioral problems and while controlling for child group status (DEV or GEN), caregiver education and age, and amount of TV viewing. Reading promotion programs should focus on children from low socioeconomic environments regardless of disability risk status.

Paying attention to reading: the neurobiology of reading and dyslexia

Extraordinary progress in functional brain imaging, primarily advances in functional magnetic resonance imaging, now allows scientists to understand the neural systems serving reading and how these systems differ in dyslexic readers. Scientists now speak of the neural signature of dyslexia, a singular achievement that for the first time has made what was previously a hidden disability, now visible. Paralleling this achievement in understanding the neurobiology of dyslexia, progress in the identification and treatment of dyslexia now offers the hope of identifying children at risk for dyslexia at a very young age and providing evidence-based, effective interventions. Despite these advances, for many dyslexic readers, becoming a skilled, automatic reader remains elusive, in great part because though children with dyslexia can be taught to decode words, teaching children to read fluently and automatically represents the next frontier in research on dyslexia. We suggest that to break through this "fluency" barrier, investigators will need to reexamine the more than 20-year-old central dogma in reading research: the generation of the phonological code from print is modular, that is, automatic and not attention demanding, and not requiring any other cognitive process. Recent findings now present a competing view: other cognitive processes are involved in reading, particularly attentional mechanisms, and that disruption of these attentional mechanisms play a causal role in reading difficulties. Recognition of the role of attentional mechanisms in reading now offer potentially new strategies for interventions in dyslexia. In particular, the use of pharmacotherapeutic agents affecting attentional mechanisms not only may provide a window into the neurochemical mechanisms underlying dyslexia but also may offer a potential adjunct treatment for teaching dyslexic readers to read fluently and automatically. Preliminary studies suggest that agents traditionally used to treat disorders of attention, particularly attention-deficit/hyperactivity disorder, may prove to be an effective adjunct to improving reading in dyslexic students.

Impact of neurofibromatosis type 1 on school performance

School functioning of 86 Dutch neurofibromatosis type 1 children (7-17 years) using teacher questionnaires was analyzed to determine the impact of neurofibromatosis type 1 on school performance. In all, 75% of the neurofibromatosis type 1 children performed more than 1 standard deviation below grade peers in at least one of the domains of spelling, mathematics, technical reading or comprehensive reading. Furthermore, neurofibromatosis type 1 children had a 4-fold increased risk for attending special education and a 6-fold increased risk for receiving remedial teaching for learning, behavior, speech, or motor problems. Children without apparent learning disabilities still frequently displayed neuropsychological deficits. Only 10% of the children did not show any school-functioning problems. Finally, it was found that the clinical severity of neurofibromatosis type 1 correlated with the cognitive deficits. Taken together, it was shown that neurofibromatosis type 1 has profound impact on school performance. Awareness of these problems may facilitate timely recognition and appropriate support.

Dificuldades no diagnóstico de TDAH em crianças

O transtorno do déficit de atenção e/ou hiperatividade (TDAH) é uma doença de alta prevalência em crianças em idade escolar. Erroneamente entendido anteriormente como um diagnóstico de baixa morbidade, o TDAH é reconhecido atualmente como uma condição importante, não só pelo forte impacto funcional e social como também pela alta prevalência de comorbidades psiquiátricas. Déficits cognitivos globais e transtornos invasivos do desenvolvimento assim como transtornos do aprendizado são condições complexas que, quando estão associadas aos sintomas de TDAH, têm seus quadros agravados, requerendo maior atenção e estratégias de tratamento mais individualizadas. O objetivo deste artigo é uma discussão sobre esses diagnósticos diferenciais que representam um desafio na prática clínica.