Trajectories of Growth Associated With Long-Term Stimulant Medication in the Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder

Clinical practice guidelines for the care of girls and women with Turner syndrome

Turner syndrome (TS) affects 50 per 100 000 females. TS affects multiple organs through all stages of life, necessitating multidisciplinary care. This guideline extends previous ones and includes important new advances, within diagnostics and genetics, estrogen treatment, fertility, co-morbidities, and neurocognition and neuropsychology. Exploratory meetings were held in 2021 in Europe and United States culminating with a consensus meeting in Aarhus, Denmark in June 2023. Prior to this, eight groups addressed important areas in TS care: (1) diagnosis and genetics, (2) growth, (3) puberty and estrogen treatment, (4) cardiovascular health, (5) transition, (6) fertility assessment, monitoring, and counselling, (7) health surveillance for comorbidities throughout the lifespan, and (8) neurocognition and its implications for mental health and well-being. Each group produced proposals for the present guidelines, which were meticulously discussed by the entire group. Four pertinent questions were submitted for formal GRADE (Grading of Recommendations, Assessment, Development and Evaluation) evaluation with systematic review of the literature. The guidelines project was initiated by the European Society for Endocrinology and the Pediatric Endocrine Society, in collaboration with members from the European Society for Pediatric Endocrinology, the European Society of Human Reproduction and Embryology, the European Reference Network on Rare Endocrine Conditions, the Society for Endocrinology, and the European Society of Cardiology, Japanese Society for Pediatric Endocrinology, Australia and New Zealand Society for Pediatric Endocrinology and Diabetes, Latin American Society for Pediatric Endocrinology, Arab Society for Pediatric Endocrinology and Diabetes, and the Asia Pacific Pediatric Endocrine Society. Advocacy groups appointed representatives for pre-meeting discussions and the consensus meeting.

Managing Growth Deceleration Associated With Attention-Deficit/Hyperactivity Disorder and Stimulant-Induced Appetite Suppression

Attention-deficit/hyperactivity disorder (ADHD) has been diagnosed in 9.8% of children ages 3 to 17 years in the United States according to Centers for Disease Control and Prevention data from 2016 to 2019, and 62% of children with ADHD take medication as part of their treatment.1 Due to their well-established safety profile and high efficacy, central nervous system stimulants are used as first-line treatment for symptom reduction in children with ADHD.2 For each patient, benefits of stimulant medications must be weighed against risks, which may include appetite suppression and weight loss in children. Since the benefits of stimulants were first established, concern has grown for stimulant-associated growth deceleration and shorter adult height.

Treatment Outcomes With Licensed and Unlicensed Stimulant Doses for Adults With Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis

Importance

Stimulants (methylphenidate and amphetamines) are often prescribed at unlicensed doses for adults with attention-deficit/hyperactivity disorder (ADHD). Whether dose escalation beyond US Food and Drug Administration recommendations is associated with positive risk benefits is unclear.

Objective

To investigate the impact, based on averages, of stimulant doses on treatment outcomes in adults with ADHD and to determine, based on averages, whether unlicensed doses are associated with positive risk benefits compared with licensed doses.

Data Sources

Twelve databases, including published (PubMed, Cochrane Library, Embase, Web of Sciences) and unpublished (ClinicalTrials.gov) literature, up to February 22, 2023, without language restrictions.

Study Selection

Two researchers independently screened records to identify double-blinded randomized clinical trials of stimulants against placebo in adults (18 years and older) with ADHD.

Data Extraction and Synthesis

Aggregate data were extracted and synthesized in random-effects dose-response meta-analyses and network meta-analyses.

Main Outcome Measures

Change in ADHD symptoms and discontinuations due to adverse events.

Results

A total of 47 randomized clinical trials (7714 participants; mean age, 35 (SD, 11) years; 4204 male [56%]) were included. For methylphenidate, dose-response curves indicated additional reductions of symptoms with increments in doses, but the gains were progressively smaller and accompanied by continued additional risk of adverse events dropouts. Network meta-analyses showed that unlicensed doses were associated with greater reductions of symptoms compared with licensed doses (standardized mean difference [SMD], -0.23; 95% CI, -0.44 to -0.02; very low certainty of evidence), but the additional gain was small and accompanied by increased risk of adverse event dropouts (odds ratio, 2.02; 95% CI, 1.19-3.43; moderate certainty of evidence). For amphetamines, the dose-response curve approached a plateau and increments in doses did not indicate additional reductions of symptoms, but there were continued increments in the risk of adverse event dropouts. Network meta-analysis did not identify differences between unlicensed and licensed doses for reductions of symptoms (SMD, -0.08; 95% CI, -0.24 to 0.08; very low certainty of evidence).

Conclusions and Relevance

Based on group averages, unlicensed doses of stimulants may not have positive risk benefits compared with licensed doses for adults with ADHD. In general, practitioners should consider unlicensed doses cautiously. Practitioners may trial unlicensed doses if needed and tolerated but should be aware that there may not be large gains in the response to the medication with those further increments in dose. However, the findings are averages and will not generalize to every patient.

Associations Between Attention-Deficit/Hyperactivity Disorder (ADHD), ADHD Medication, and Shorter Height: A Quasi-Experimental and Family-Based Study

OBJECTIVE

The association between attention-deficit/hyperactivity disorder (ADHD) and shorter height is unclear. This study examined the risk of shorter height in individuals with ADHD, and the influence of prenatal factors, ADHD medication, psychiatric comorbidity, socioeconomic factors, and familial liability.

METHOD

We drew on Swedish National Registers for 2 different study designs. First, height data for 14,268 individuals with ADHD and 71,339 controls were stratified into 2 groups: (1) before stimulant treatment was introduced in Sweden, and (2) after stimulant treatment was introduced in Sweden. Second, we used a family-based design including 833,172 relatives without ADHD with different levels of relatedness to the individuals with ADHD and matched controls.

RESULTS

ADHD was associated with shorter height both before (below-average height: OR = 1.31, 95% CI = 1.22-1.41) and after (below-average height: OR = 1.21, 95% CI = 1.13-1.31) stimulants for ADHD were introduced in Sweden, and was of similar magnitude in both cohorts. The association between ADHD and shorter height attenuated after adjustment for prenatal factors, psychiatric disorders, and socioeconomic status. Relatives of individuals with ADHD had an increased risk of shorter height (below-average height in full siblings: OR = 1.14, 95% CI = 1.09-1.19; maternal half siblings: OR = 1.10, 95% CI = 1.01-1.20; paternal half siblings: OR = 1.15, 95% CI = 1.07-1.24, first full cousins: OR = 1.10, 95% CI = 1.08-1.12).

CONCLUSION

Our findings suggest that ADHD is associated with shorter height. On a population level, this association was present both before and after ADHD medications were available in Sweden. The association between ADHD and height was partly explained by prenatal factors, psychiatric comorbidity, low socioeconomic status, and a shared familial liability for ADHD.

Growth Trajectories in Stimulant Treated Children and Adolescents: A Qualitative Review of the Literature from Comprehensive Datasets and Registries

Objective: Attention-deficit/hyperactivity disorder (ADHD) treatment with stimulant products has been shown to be safe and effective; however, there are remaining concerns about their possible adverse effects on growth trajectories. We conducted a systematic review of the extant literature derived from ecologically valid databases and registries to assess the body of knowledge about the effects of stimulants on growth trajectories in naturalistic samples. Methods: Using PubMed and PsycINFO, we searched for articles published before February 8, 2023 that focused on growth findings associated with stimulant treatment in pediatric ADHD from comprehensive datasets derived from naturalistic population studies. Results: Of the 1070 articles initially identified, 12 met all inclusion criteria. Sample sizes ranged from 157 to 163,820 youths. Seven of 10 articles examining height found significant decreases in height associated with chronic stimulant treatment that normalized over time in 2 studies. Three articles found no significant association between stimulant treatment and height. No clear associations were identified between cumulative duration and dose of stimulant treatment and adult height. All articles examining weight and six of eight articles examining body mass index (BMI) found significant initial decreases that tended to normalize then increase over time. Longer duration of stimulant medication use was predominantly associated with significant weight and BMI reductions. The effects of stimulant dose on weight and BMI were mostly weak and clinically insignificant. Most studies found no significant association between age at start of stimulant treatment and change in height, weight, or BMI. Most studies did not find significant sex effects in relation to growth parameters. Conclusions: This review of ecologically informative samples revealed that the effects of stimulant treatment on growth trajectories are mainly small and transient. These effects seem to be clinically insignificant for most youth with ADHD who receive stimulant treatment from childhood onto adolescence and adulthood.

Efficacy of stimulants for preschool attention-deficit/hyperactivity disorder: A systematic review and meta-analysis

Background

Robust synthesis of evidence to support treatment recommendations for preschoolers with attention-deficit/hyperactivity disorder (ADHD) is lacking. The aim of this systematic review and meta-analysis was to review currently available evidence to evaluate the efficacy and acceptability of stimulants for preschool children with ADHD.

Methods

We searched electronic databases (CENTRAL, Embase, PubMed) from the database inception to March, 2022; and clinical trial registries through WHO ICTRP from the database inception to July, 2022, and selected double-blinded randomized controlled trials (RCTs) that compared stimulants against placebo for the treatment of preschoolers (age ≤ 7 years) with ADHD. Change in ADHD symptom severity was the primary outcome (efficacy) and all-cause dropout rates (acceptability) was the secondary outcome. Data were pooled with random-effects models weighted by the inverse of the variance. Risk of bias of individual studies were assessed with the Cochrane Risk of Bias tool version 2. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess the quality of evidence. This study is registered with PROSPERO (CRD42022348597).

Results

Five RCTs (three methylphenidate immediate-release, one methylphenidate extended-release, and one lisdexamfetamine) were included. The analysis of efficacy was based on 489 participants. Meta-analysis of change in ADHD symptom severity demonstrated a significant effect in favor of stimulants over placebo (standardized mean difference = -0.59; 95% CI -0.77, -0.41; p < 0.0001). There was no evidence of heterogeneity but some concerns about publication bias. Regardless, the confidence of evidence was considered moderate. For acceptability, stimulants did not lead to an increased rate of all-cause discontinuation rates in comparison to placebo (OR = 0.59; 95% CI 0.15, 2.37; p = 0.45) but the confidence of estimate was very low.

Conclusions

Our findings demonstrated that stimulants are efficacious in reducing ADHD symptoms among preschool children. Clinicians should consider the use of stimulants when making treatment recommendations for preschoolers with ADHD.

Association Between Stimulant Treatment and Substance Use Through Adolescence Into Early Adulthood

Importance

Possible associations between stimulant treatment of attention-deficit/hyperactivity disorder (ADHD) and subsequent substance use remain debated and clinically relevant.

Objective

To assess the association of stimulant treatment of ADHD with subsequent substance use using the Multimodal Treatment Study of ADHD (MTA), which provides a unique opportunity to test this association while addressing methodologic complexities (principally, multiple dynamic confounding variables).

Design, Setting, and Participants

MTA was a multisite study initiated at 6 sites in the US and 1 in Canada as a 14-month randomized clinical trial of medication and behavior therapy for ADHD but transitioned to a longitudinal observational study. Participants were recruited between 1994 and 1996. Multi-informant assessments included comprehensively assessed demographic, clinical (including substance use), and treatment (including stimulant treatment) variables. Children aged 7 to 9 years with rigorously diagnosed DSM-IV combined-type ADHD were repeatedly assessed until a mean age of 25 years. Analysis took place between April 2018 and February 2023.

Exposure

Stimulant treatment of ADHD was measured prospectively from baseline for 16 years (10 assessments) initially using parent report followed by young adult report.

Main Outcomes and Measures

Frequency of heavy drinking, marijuana use, daily cigarette smoking, and other substance use were confidentially self-reported with a standardized substance use questionnaire.

Results

A total of 579 children (mean [SD] age at baseline, 8.5 [0.8] years; 465 [80%] male) were analyzed. Generalized multilevel linear models showed no evidence that current (B [SE] range, -0.62 [0.55] to 0.34 [0.47]) or prior stimulant treatment (B [SE] range, -0.06 [0.26] to 0.70 [0.37]) or their interaction (B [SE] range, -0.49 [0.70] to 0.86 [0.68]) were associated with substance use after adjusting for developmental trends in substance use and age. Marginal structural models adjusting for dynamic confounding by demographic, clinical, and familial factors revealed no evidence that more years of stimulant treatment (B [SE] range, -0.003 [0.01] to 0.04 [0.02]) or continuous, uninterrupted stimulant treatment (B [SE] range, -0.25 [0.33] to -0.03 [0.10]) were associated with adulthood substance use. Findings were the same for substance use disorder as outcome.

Conclusions and Relevance

This study found no evidence that stimulant treatment was associated with increased or decreased risk for later frequent use of alcohol, marijuana, cigarette smoking, or other substances used for adolescents and young adults with childhood ADHD. These findings do not appear to result from other factors that might drive treatment over time and findings held even after considering opposing age-related trends in stimulant treatment and substance use.

Examining Factors Associated With Medication Adherence in Youth With Bipolar Disorder

Objective

To assess medication adherence and factors associated with poor adherence in youth with bipolar disorder (BD) followed from adolescence through young adulthood.

Method

Participants with BD recruited through the Course and Outcome of Bipolar Youth (COBY) study were included in this study if they were prescribed psychotropic medications and had at least 3 follow-up assessments of medication adherence (N= 179, ages 12-36). Medication adherence had been evaluated for a median of 8 years using a questionnaire derived from the Coronary Artery Risk Development in Young Adults (CARDIA) study. For the longitudinal evaluation, adherence was measured as the percentage of follow-up assessments in which the participants did not endorse any of the nonadherence items included in the questionnaire. Concurrent and future predictors of poor adherence were assessed using both univariate and multivariate longitudinal analyses.

Results

Among the participants, 51% reported poor adherence in more than 50% of their follow-up assessments. Younger age, family conflicts, polypharmacy, lower functioning, greater severity of mood symptoms, and comorbid disorders were associated with poor adherence in the univariate analyses. In the multivariate analyses, comorbid ADHD was the single most influential factor associated with concurrent and future poor adherence in all age groups. Participants' most reported reasons for poor adherence were forgetfulness (56%), negative attitudes toward medication treatment (10.5%), and disturbed daily routine (7%).

Conclusions

Poor medication adherence is a significant problem in youth with BD with the most influential factor being the presence of comorbid ADHD. Thus, it is important to identify and appropriately treat comorbid ADHD to improve medication adherence and patients' prognosis. Providers should also recommend tools to enhance consistent medication intake and address patients' concerns and negative beliefs about their illness and treatment.

An updated safety review of the current drugs for managing ADHD in children

INTRODUCTION

Attention-Deficit/Hyperactivity Disorder (ADHD) is a highly prevalent condition that causes persistent problems with attention and/or hyperactivity-impulsivity and often results in significant impairment when left untreated. Medications for this disorder continue to evolve and provide new treatment options. Ongoing review of related medication safety and tolerability remains an important task for prescribers.

AREAS COVERED

This manuscript provides an updated safety review of medications used to treat ADHD in children and adolescents. PubMed and OneSearch online databases were utilized to search for literature relevant to the topic of ADHD medications and safety. Clinical trials of medications used to treat ADHD, systematic reviews and meta-analyses, and articles covering specific safety issues (adverse or unfavorable events) such as cardiovascular effects, seizures, impact on growth, depression, suicidal ideation, substance use disorders, psychosis, and tics are described.

EXPERT OPINION

Available pharmacologic treatments for ADHD have favorable efficacy, safety and tolerability and allow many patients to achieve significant improvement of their symptoms. Despite the availability of multiple stimulant and non-stimulant formulations, some individuals with ADHD may not tolerate available medications or attain satisfactory improvement. To satisfy unmet clinical needs, ADHD pharmaceutical research with stimulant and nonstimulant formulations targeting dopamine, norepinephrine, and novel receptors is ongoing.

Neurofeedback for Attention-Deficit/Hyperactivity Disorder: 25-Month Follow-up of Double-Blind Randomized Controlled Trial

OBJECTIVE

To examine delayed effects of theta-beta ratio (TBR) neurofeedback (NF) for attention-deficit/hyperactivity disorder (ADHD) 25 months after baseline, ∼21 months after end of treatment.

METHOD

Children aged 7 to 10 years with rigorously diagnosed ADHD had been randomized to 38 sessions of TBR NF (n = 84) or control treatment (n = 58) of identical appearance, intensity/frequency, and duration, differing only in that reinforcement for controls was based on a pre-recorded electroencephalogram (EEG) of another child. Child, parent, and all site staff were blinded until after 25-month assessments, with only one-fourth able to guess the control treatment correctly. Baseline assessments were repeated off medication after 25 months.

RESULTS

Of the 142 participants, 120 had 25-month follow-up (84.5% retention). Only 12 participants (6 controls) had NF after the study treatment, greatly retaining the randomization. The primary outcome, parent-rated inattention, was not significantly different between treatments despite large pre-post effect sizes (NF recipients, d = 1.63; controls, d = 1.42). Most secondary measures showed the same pattern. Response rates (Clinical Global Impression-Improvement ≤2) were 58.6% of NF recipients and 66% of controls (not significant). Marginally more controls than NF recipients needed medication (57.1% vs 38.6%, p = .059); specifically, 7.1% of NF recipients and 4% of controls had reduced medication need, whereas 34.3% of NF recipients and 50% of controls needed more medication (p = 0.084).

CONCLUSION

Most of the large within-group improvement from the NF treatment package reported by unblinded studies and replicated in this blinded study reflects nonspecific effects, not specific effects of deliberate down-training of EEG theta-beta power ratio. At 25-month follow-up, it appears comparable to the evidence-based Multimodal Treatment Study of ADHD (MTA) treatments, suggesting a psychotherapeutic/behavioral effect.

CLINICAL TRIAL REGISTRATION INFORMATION

Double-Blind 2-Site Randomized Clinical Trial of Neurofeedback for ADHD; http://clinicaltrials.gov/; NCT02251743.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. We actively worked to promote sex and gender balance in our author group.

Methylphenidate Promotes Premature Growth Plate Closure: In Vitro Evidence

It is well known that patients with attention deficit hyperactivity disorder treated with stimulants, such as methylphenidate hydrochloride (MPH), have reduced height and weight. Even though MPH has an anorexigenic effect, an additional impact of this drug on the growth plate cannot be discarded. In this study, we aimed to determine the cellular effect of MPH on an in vitro growth plate model. We tested the effects of MPH on the viability and proliferation of a prechondrogenic cell line via an MTT assay. In vitro differentiation of this cell line was performed, and cell differentiation was evaluated through the expression of cartilage- and bone-related genes as measured via RT-PCR. MPH did not alter the viability or proliferation of prechondrogenic cells. However, it reduced the expression of cartilage extracellular matrix-related genes (type II collagen and aggrecan) and increased the expression of genes involved in growth plate calcification (Runx2, type I collagen, and osteocalcin) at different phases of their differentiation process. Our results evidence that MPH upregulates genes associated with growth plate hypertrophic differentiation. This may induce premature closure of the growth plate, which would contribute to the growth retardation that has been described to be induced by this drug.

Ghrelin regulates hyperactivity-like behaviors via growth hormone signaling pathway in zebrafish (Danio rerio)

INTRODUCTION

Ghrelin is originally identified as the endogenous ligand for the growth hormone secretagogue receptor (GHSR) and partially acts by stimulating growth hormone (GH) release. Our previous studies have identified GHRELIN as a novel susceptibility gene for human attention-deficit hyperactivity disorder (ADHD), and ghrelin-depleted zebrafish (Danio rerio) display ADHD-like behaviors. However, the underlying molecular mechanism how ghrelin regulates hyperactivity-like behaviors is not yet known.

RESULTS

Here, we performed RNA-sequencing analysis using adult ghrelin ^Δ/Δ zebrafish brains to investigate the underlying molecular mechanisms. We found that gh1 mRNA and genes related to the gh signaling pathway were significantly reduced at transcriptional expression levels. Quantitative polymerase chain reaction (qPCR) was performed and confirmed the downregulation of gh signaling pathway-related genes in ghrelin ^Δ/Δ zebrafish larvae and the brain of adult ghrelin ^Δ/Δ zebrafish. In addition, ghrelin ^Δ/Δ zebrafish displayed hyperactive and hyperreactive phenotypes, such as an increase in motor activity in swimming test and a hyperreactive phenotype under light/dark cycle stimulation, mimicking human ADHD symptoms. Intraperitoneal injection of recombinant human growth hormone (rhGH) partially rescued the hyperactivity and hyperreactive-like behaviors in ghrelin mutant zebrafish.

CONCLUSION

Our results indicated that ghrelin may regulate hyperactivity-like behaviors by mediating gh signaling pathway in zebrafish. And the protective effect of rhGH on ghrelin ^Δ/Δ zebrafish hyperactivity behavior provides new therapeutic clues for ADHD patients.

Thalamocortical functional connectivity and cannabis use in men with childhood attention-deficit/hyperactivity disorder

Disruptions of the cortico-striato-thalamo-cortical circuit has been implicated in both attention-deficit/hyperactivity disorder and substance use disorder. Given the high prevalence of cannabis use among patients with attention-deficit/hyperactivity disorder, we set out to investigate the relationship between the two in the thalamus. We analyzed resting-state functional magnetic resonance imaging data obtained from the Addiction Connectome Preprocessed Initiative Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder database. Functional connectivity maps were extracted to compare thalamic connectivity among adults who had been diagnosed with attention-deficit/hyperactivity disorder during childhood according to whether or not they used cannabis. The study participants included 18 cannabis users and 15 cannabis non-users with childhood attention-deficit/hyperactivity disorder. Our results revealed that adults with attention-deficit/hyperactivity disorder who used cannabis (n = 18) had significantly decreased functional connectivity between the thalamus and parietal regions, which was particularly prominent in the inferior parietal areas, in comparison with those who did not use cannabis (n = 15). Left thalamic functional connectivity with the inferior parietal and middle frontal areas and right thalamic functional connectivity with the inferior parietal and superior frontal areas were increased in non-users of cannabis with attention-deficit/hyperactivity disorder compared with a local normative comparison group (n = 7). In conclusion, adults with a childhood history of attention-deficit/hyperactivity disorder who do not use cannabis often have relatively stronger thalamoparietal and thalamofrontal connectivity, which may help reduce the risk of cannabis use.

Effect of stimulants on final adult height

BACKGROUND

The use of stimulant medications for treatment of ADHD has raised concern as to whether they adversely impact linear growth. Previous studies have indicated that stimulant medications may suppress growth for a short period after treatment initiation; however, more information is needed to evaluate the long-term effects on final adult stature. This mini review aims to evaluate the effect of stimulant medications on final adult height in children with ADHD.

CONTENTS

We performed a literature review across PubMed/MEDLINE database. Only articles that included data on final adult height or near final adult height (age≥16 or 17 years) were included.

SUMMARY

Early studies investigating the long-term impacts of stimulant medications observed growth suppression during the active treatment period, but when comparing final adult height, there was no difference between the control and ADHD groups. A recent larger comprehensive study (Multimodal Treatment of ADHD study) has suggested that the long-term use of significant doses of stimulants during childhood may compromise final adult height to a clinically significant degree when comparing adult height across three long-term patterns of stimulant treatment (Consistent, Intermittent, Negligible). The consistent use subgroup was significantly shorter than other subgroups.

OUTLOOK

For children with ADHD, a significant long-term dose of stimulant treatment should be used with caution to avoid diminishing adult height potential. Pediatric endocrinologists should consider chronic use of stimulants as a factor contributing to reduced adult height.

Parental perspectives on attention-deficit/hyperactivity disorder treatments for children

This study investigated parental perspectives and experiences on the evaluation and treatment process associated with attention-deficit/hyperactivity disorder (ADHD). Five hundred sixty-eight parents of youth 2-28 years-old (M = 9.37; SD = 4.11) diagnosed with ADHD responded to a 14-item online survey about their child's diagnosis and treatment. Parents reported that they had tried an average of 4.49 interventions (SD = 2.63). Parents further shared factors in treatment selection, most helpful parenting strategies, and preferences for types of treatments and treatment targets. A majority of parents reported incorporating many non-traditional strategies (e.g., exercise, healthy eating, outdoor activities) with goals of improving their child's coping skills, study habits, and anger management. The findings show that treatment choices were often selected based on trust in the provider, research support, and the child's preference. Given parental preferences for non-traditional strategies, treatment development efforts should consider these strategies as a component of a broader multimodal treatment approach to ADHD.

Possible Association between Methylphenidate and Mandibular Bone Characteristics Detected by Dental Panoramic Radiograph in Children and Adolescents with ADHD

Some studies have shown that children treated with psychostimulants for attention-deficit hyperactivity disorder (ADHD) have decreased bone mineral density (BMD). Mandibular cortical width (MCW) may be used as a surrogate measure for evaluating BMD. We compared the MCW measured on digital panoramic radiographs (DPR) of 38 children and adolescents with ADHD who were treated with methylphenidate for at least 12 months to the MCW of 58 children and adolescents without ADHD (control). The two groups had a similar mean age (p = 0.3). Mean MCW was significantly lower among children with ADHD compared to those in the control group (2.77 ± 0.33 mm vs. 3.04 ± 0.46 mm, p = 0.004). Additionally, each of the MCW sides were significantly smaller in the group with ADHD compared with the control group. In conclusion, treatment with methylphenidate is associated with low MCW in children and adolescents with ADHD. Analysis of MCW on DPR may help in screening children that are at risk of bone health alterations that may result in low BMD in adulthood. Dentists may be the first to identify bone health abnormalities and should be aware of their role in referring their patients to further follow-up.

Growth Hormone and Thyroid Function in Children With Attention Deficit Hyperactivity Disorder Undergoing Drug Therapy

CONTEXT

The trends in hormone indices of children with attention deficit hyperactivity disorder (ADHD) who received long-term medication treatment remains controversial.

OBJECTIVE

This prospective study aimed to examine the changes in the growth hormone and thyroid hormone systems among children with ADHD undergoing various medication treatments.

METHODS

In total, 118 children who were diagnosed with ADHD and were drug-naive were observed naturalistically over 12 months. Of them, 22 did not receive any medication, while 39, 40, and 17 were treated with low doses of short-acting methylphenidate (MPH) (14 ± 6.7 mg/day), osmotic-release oral system (OROS) long-acting MPH (32 ± 9.6 mg/day), and atomoxetine (29.2 ± 9.7 mg/day), respectively. Blood samples were obtained at both the baseline and the endpoint (month 12) to measure serum levels of insulin-like growth factor 1 (IGF-1), IGF binding protein 3 (IGFBP-3), prolactin, thyroid-stimulating hormone (TSH), triiodothyronine (T3), thyroxine (T4), and free T4.

RESULTS

Trends for IGF-1, IGFBP-3, prolactin, TSH, T3, T4, and free T4 levels were similar among the 4 groups. Changes in serum levels of IGF-1 were positively correlated with changes in height and weight of all the children with ADHD. However, patients who received MPH treatment had less body weight gain than the nonmedicated group. The ratio of MPH doses to body weight was inversely correlated with the increment in height.

CONCLUSION

There were no changes in thyroid or growth hormones associated with the low doses of ADHD medications used in this study within 1 year's duration. Nonetheless, patients' growth and the appropriateness of drug dosage should be closely monitored.

Trialling a microbiome-targeted dietary intervention in children with ADHD-the rationale and a non-randomised feasibility study

Background

Dietary interventions have been previously explored in children with ADHD. Elimination diets and supplementation can produce beneficial behaviour changes, but little is known about the mechanisms mediating change. We propose that these interventions may work, in part, by causing changes in the gut microbiota. A microbiome-targeted dietary intervention was developed, and its feasibility assessed.

Methods

A non-randomised feasibility study was conducted on nine non-medicated children with ADHD, aged 8–13 years (mean 10.39 years), using a prospective one-group pre-test/post-test design. Participants were recruited from ADHD support groups in London and took part in the 6-week microbiome-targeted dietary intervention, which was specifically designed to impact the composition of gut bacteria. Children were assessed pre- and post-intervention on measures of ADHD symptomatology, cognition, sleep, gut function and stool-sample microbiome analysis. The primary aim was to assess the study completion rate, with secondary aims assessing adherence, adverse events (aiming for no severe and minimal), acceptability and suitability of outcome measures.

Results

Recruitment proved to be challenging and despite targeting 230 participants directly through support groups, and many more through social media, nine families (of the planned 10) signed up for the trial. The completion rate for the study was excellent at 100%. Exploration of secondary aims revealed that (1) adherence to each aspect of the dietary protocol was very good; (2) two mild adverse events were reported; (3) parents rated the treatment as having good acceptability; (4) data collection and outcome measures were broadly feasible for use in an RCT with a few suggestions recommended; (5) descriptive data for outcome measures is presented and suggests that further exploration of gut microbiota, ADHD symptoms and sleep would be helpful in future research.

Conclusions

This study provides preliminary evidence for the feasibility of a microbiome-targeted dietary intervention in children with ADHD. Recruitment was challenging, but the diet itself was well-tolerated and adherence was very good. Families wishing to trial this diet may find it an acceptable intervention. However, recruitment, even for this small pilot study, was challenging. Because of the difficulty experienced recruiting participants, future randomised controlled trials may wish to adopt a simpler dietary approach which requires less parental time and engagement, in order to recruit the number of participants required to make meaningful statistical interpretations of efficacy.

Trial registration

ClinicalTrials.gov Identifier: NCT03737877. Registered 13 November 2018—retrospectively registered, within 2 days of the first participant being recruited.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01058-4.

Micronutrients for Attention-Deficit/Hyperactivity Disorder in Youths: A Placebo-Controlled Randomized Clinical Trial

OBJECTIVE

To evaluate whether micronutrients (vitamins/minerals) benefit attention-deficit/hyperactivity disorder (ADHD) and irritability in a North American pediatric sample.

METHOD

A 3-site, 8-week, placebo-controlled, randomized clinical trial of micronutrients was conducted in nonmedicated children aged 6 to 12 years with ADHD and at least 1 impairing irritability symptom by parent report on the Child and Adolescent Symptom Inventory-5 (CASI-5). A priori-defined primary outcomes were Clinical Global Impression-Improvement (CGI-I) (CGI-I of 1 or 2 = treatment responder) and parent-rated CASI-5 composite score of ADHD, oppositional defiant, disruptive mood dysregulation, and peer conflict symptoms, including impairment scores.

RESULTS

Of 135 randomized (mean age 9.8 years), 126 youths (93%) comprised the modified intention-to-treat population. Blinding was maintained. For the CGI-I, 54% of the micronutrient and 18% of the placebo group were responders (risk ratio = 2.97, 97.5% CI = 1.50, 5.90, p < .001). CASI-5 composite scores improved significantly for both groups (p < .01), with a mean change of -0.31 (95% CI = -0.39, -0.23) in the micronutrient group and a mean change of -0.28 (95% CI = -0.38, -0.19) in the placebo group. However, the between-group difference was not significant (mean change = -0.02; 97.5% CI = -0.16, 0.12, effect size = 0.07, p = .70). The micronutrient group grew 6 mm more than the placebo group (p = .002). No serious adverse events or clinically significant changes from baseline in blood and urine tests occurred.

CONCLUSION

Micronutrients showed global benefit over placebo by blinded clinician rating, but not by parent-report CASI-5 composite rating in a population with ADHD and irritability. Micronutrients showed greater height growth. Micronutrients were well tolerated, and the majority of participants adhered to the number of capsules prescribed. This randomized controlled trial replicates safety and efficacy reported for ADHD in 2 smaller trials of a similar formula containing all vitamins and known essential minerals in amounts between the Recommended Dietary Allowance and Upper Tolerable Intake Level.

CLINICAL TRIAL REGISTRATION INFORMATION

Micronutrients for ADHD in Youth (MADDY) Study; https://clinicaltrials.gov; NCT03252522.

Clinical Efficacy Evaluation of Psychological Nursing Intervention Combined with Drugs Treatment of Children with ADHD under Artificial Intelligence

ADHD in children is one of the most common neurodevelopmental disorders. It is manifested as inattention, hyperactivity, impulsiveness, and other symptoms that are inconsistent with the developmental level in different occasions, accompanied by functional impairment in social, academic, and occupational aspects. At present, the treatment for children with ADHD is mainly based on psychological nursing intervention combined with drug therapy. Therefore, the actual efficacy evaluation of this treatment regimen is very important. Neural networks are widely used in smart medical care. This work combines artificial intelligence with the evaluation of clinical treatment effects of ADHD children and designs an intelligent model based on neural networks for evaluating the clinical efficacy of psychological nursing intervention combined with drug treatment of children with ADHD. The main research is that, for the evaluation of clinical treatment effect of ADHD in children, this paper proposes a 1D Parallel Multichannel Network (1DPMN), which is a convolutional neural network. The results show that network models can extract different data features through different channels and can achieve high accuracy evaluation of clinical efficacy of ADHD in children. On the basis of the model, performance is improved through the study of Adam optimizer to speed up the model convergence, adopts batch normalization algorithm to improve stability, and uses Dropout to improve the generalization ability of the network. Aiming at the problem of too many parameters, the 1DPMN is optimized through the principle of local sparseness, and the model parameters are greatly reduced.

The effects of stimulant dose and dosing strategy on treatment outcomes in attention-deficit/hyperactivity disorder in children and adolescents: a meta-analysis

Clinical guidelines currently recommend practitioners titrate stimulant medications, i.e., methylphenidate (MPH) and amphetamines (AMP), to the dose that maximizes symptom control without eliciting intolerable adverse events (AEs) when treating attention-deficit/hyperactivity disorder (ADHD) in school-aged children/adolescents. However, robust evidence-base regarding the effects of doses and dosing strategies of stimulants on clinical outcomes in the treatment of children/adolescents with ADHD is currently lacking and stimulants are often underdosed in clinical practice. To address this gap and provide rigorous evidence-base in relation to the dose and dosing strategy of stimulants, we conducted the largest systematic review and dose-response meta-analysis examining change in ADHD symptoms (efficacy), and treatment discontinuations due to AEs (tolerability) and any reason (acceptability). We conducted one-stage random-effects dose-response meta-analyses examining MPH and AMP separately, stratifying trials based on fixed-dose and flexible-dose design. Daily doses of stimulants were converted to MPH- and AMP-equivalent doses by adjusting for different pharmacokinetics across formulations. We also conducted pairwise meta-analyses to provide indirect comparisons between flexible-dose versus fixed-dose trials. Our study included 65 RCTs involving 7 877 children/adolescents. Meta-analyses of fixed-dose trials for both MPH and AMP demonstrated increased efficacy and increased likelihood of discontinuation due to AEs with increasing doses of stimulants. The incremental benefits of stimulants in terms of efficacy decreased beyond 30 mg of MPH or 20 mg of AMP in fixed-dosed trials. In contrast, meta-analyses of flexible-dose trials for both MPH and AMP demonstrated increased efficacy and reduced likelihood of discontinuations for any reason with increasing stimulant doses. The incremental benefits of stimulants in terms of efficacy remained constant across the FDA-licensed dose range for MPH and AMP in flexible-dose trials. Our results suggest that flexible titration as needed, i.e., considering the presence of ADHD symptoms, and tolerated, i.e., considering the presence of dose-limiting AEs, to higher doses of stimulants is associated with both improved efficacy and acceptability because practitioners can increase/reduce doses based on control of ADHD symptoms/dose-limiting AEs. Although fixed-dose trials that are required by the FDA are valuable to characterize dose-dependency, they may underestimate the true potential benefit of trialing dose-increases of stimulants in clinical practice by not allowing dose adjustment based on response and tolerability. Additional research is required to investigate potential long-term effects of using high doses of stimulants in clinical practice.

Predictors of Changes in Height, Weight, and Body Mass Index After Initiation of Central Nervous System Stimulants in Children with Attention Deficit Hyperactivity Disorder

OBJECTIVE

To identify predictors of changes in height, weight, and body mass index (BMI) in children with attention deficit hyperactivity disorder (ADHD) starting central nervous system (CNS) stimulants.

STUDY DESIGN

There were 230 medication-naïve children aged 5-12 years with ADHD who participated in a randomized trial evaluating the impact of CNS stimulants on growth over 30 months. This observational analysis focused on the 141 participants using study medication for 65 or more days in the first 6-months after starting medication. Biometric variables, ADHD, and oppositional defiant disorder symptom scores at medication initiation, and medication use over the study were examined as predictors of changes in standardized (z) height, weight, and BMI.

RESULTS

Mean changes in z-BMI, z-weight. and z-height were negative throughout the study. The most consistent predictors of change in z-BMI, z-weight, and z-height were percent days medicated and total medication exposure. Children with lower z-height and z-weight at medication initiation experienced greater z-BMI and z-weight decreases over the first 6 months on medication. Greater appetite suppression during dose optimization predicted greater decreases in z-weight over the entire study and a greater decrease in z-height over the first 6 months on medication. z-weight change correlated with z-height change. Behavioral symptoms did not predict changes in z-BMI, z-weight, or z-height.

CONCLUSIONS

How much and how often CNS stimulants are used predicts changes in z-BMI, z-weight, and z-height in children. Even smaller and lighter children may be at risk for decreases in z-weight and z-BMI. Parent ratings of appetite during dose titration may serve as feasible indicators of future weight and height change in children using CNS stimulants.

TRIAL REGISTRATION

Clinicialtrials.gov: NCT01109849.

Sex-Specific Long-Term Height and Body Mass Index Trajectories of Children Diagnosed with Attention-Deficit/Hyperactivity Disorder and Treated with Stimulants

OBJECTIVES

To evaluate the sex-specific effects of stimulants in children with attention-deficit/hyperactivity disorder (ADHD) on body mass index (BMI) z and height z trajectories.

STUDY DESIGN

A retrospective cohort study using the database of Israel Clalit Health Services was performed. Participants included 5- to 18-year-old insured patients with documentation of at least 2 consecutive prescriptions of stimulant drugs for ADHD. Participants were further compared with sex- and age-matched insured control patients without ADHD.

RESULTS

A total of 4561 (66% boys) participants with ADHD were included. Of these, 2151 (70% boys) had follow-up data for ≥2 years of treatment. A decline of ≥1 SD in height and BMI z score was observed in 10.1% and 13.2% of the cohort, respectively. During ≥2 years follow-up, boys had a greater decline in height z score (~0.2 SD) than girls (~0.06 SD). Boys' height z score continued to decline after 1 and ≥2 years, and girls' height z score declined after 1 year, and then stabilized. The trajectory of BMI z score of boys and girls was similar, showing a greater decline after 1 year, followed by an incline after ≥2 years. Younger age at stimulants initiation, better adherence, longer treatment duration, and lower socioeconomic status were correlated with a greater impact on growth attenuation. The non-ADHD group (n = 4561, 66% boys) had baseline height z score and BMI z score similar to those in children with ADHD before treatment initiation. Height z score and BMI z score were greater in children without ADHD compared with children with ADHD following 1 year of treatment (P < .001).

CONCLUSIONS

These findings highlight the importance of growth monitoring accompanied with dietary counseling in children with ADHD treated with stimulants.

Half of the children with overweight or obesity and attention-deficit/hyperactivity disorder reach normal weight with stimulants

AIM

Treatment of childhood obesity is often insufficient and may be aggravated by high co-occurrence of attention-deficit/hyperactivity disorder (ADHD). We aimed to investigate whether children with overweight or obesity normalised in weight when receiving stimulant treatment for ADHD.

METHODS

Growth data of 118 children were obtained from medical records at outpatient paediatric and children's psychiatric services in the Gothenburg area, Sweden. The children were diagnosed with ADHD and were between 6 and 17 years at the start of stimulant treatment. The pre-treatment data act as an internal control where every child is their own control.

RESULTS

At the start of treatment, 74 children had normal weight and 44 had either overweight or obesity. During the year with stimulants, the mean (SD) body mass index (BMI) in standard deviation score (SDS) decreased significantly: -0.72 (0.66) compared with 0.17 (0.43) during the year before treatment (p < 0.01). After one year with treatment, 43% of those with overweight or obesity had reached normal weight.

CONCLUSIONS

Stimulant treatment for ADHD yields significant weight loss. In children with overweight or obesity and ADHD, this is an important finding showing additional benefit in terms of weight management.

Effects of methylphenidate on height, weight and blood biochemistry parameters in prepubertal boys with attention deficit hyperactivity disorder: an open label prospective study

Background: Adverse effects of stimulants on growth in children have long been studied, but the results remain to be clarified, because metabolic changes or predictors accompanying the growth deviations were not sufficiently studied. Objective: This open label-prospective study investigated the effects of methylphenidate (MPH) on weight, height, blood biochemistry in children with attention deficit hyperactivity disorder (ADHD). Method: Prepubertal boys treated with MPH in Child and Adolescent Psychiatry Clinic at Antalya Training and Research Hospital in Health Sciences University, Turkey were recruited. Height and weight z-scores and fasting blood samples were taken at baseline and 6^th month. Changes were compared by paired-samples t-test or Wilcoxon signed-rank test. Any association between the changes in growth and biochemical values was analyzed by Spearman's Rank-Order Correlation. The statistical significance threshold was p<0.01. Results: 31 boys aged 74 to 104 months were enrolled in the study sample (mean=87.6, Standard Deviation (SD)=9.2). Osmotic release oral system-MPH (18 mg/day) was used in 77.4% (N=24) and immediate release-MPH (5 mg three times a day) in 22.5% (N=7). Average daily drug dose was 0.66 mg/kg (SD=0.12). Baseline weight z-score was 0.63 (SD=1.12), decreased significantly at 6 months (0.24 [SD=1.04]) (Z=-4.44, p=0.000, r=0.5) (median z-score was 0.53 at baseline, -0.11 at 6 months). Baseline height z-score (0.23[SD=0.87]) was not suppressed significantly at 6 months (0.28[SD=0.85])(t(30) = ‒1.50, p=0.14). Glucose (t(30) = -4.33, p=0.000, r=0.6), creatinine (t(30)=-3.28, p=0.003, r=0.5) and 25OH-VitD (N=29, Z=-3.98, p=0.000, r=0.5) increased but alkaline phosphatase (ALP) decreased (t(28)=3.63, p=0.001, r=0.5). The differences in W-SDS and ALP were positively correlated (r=0.47, p=0.009). Conclusions: Our results indicate the importance of monitoring blood variables that may accompany growth changes early in MPH treatment and should be further assessed in larger samples.

The Occurrence of Overweight and Obesity in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder According to Three Different Diagnostic Criteria for Obesity

Objective: This study aimed to assess the prevalence of overweight and obesity in the group of children and adolescents with attention-deficit/hyperactivity disorder (ADHD) according to three different diagnostic criteria for obesity. The effect of ADHD treatment on the risk of obesity was controlled. Materials and Methods: The study group consisted of 58 subjects aged from 8 to 17 years with ADHD. Control group consisted of 62 healthy age- and sex-matched children and adolescents. Overweight and obesity were assessed according to International Obesity Task-Force (IOTF), World Health Organization (WHO) and European Childhood Obesity Group (ECOG) criteria. Results: There was a significantly higher incidence of obesity in ADHD group according to WHO (ADHD vs. Control: 17.2% vs. 3.2%, p = 0.01) and IOTF criteria (ADHD vs. Control: 10.3% vs. 1.6%, p = 0.04), but no significant difference according to ECOG criteria. There was significantly higher occurrence of overweight (20.7% vs. 12.8%, p < 0.001), obesity (10.3% vs. 3.5%, p < 0.001), and overweight and obesity (31.0% vs. 16.3%, p < 0.001) in the ADHD group compared to the Polish population. The analysis did not show a statistically significant relationship between the amount of taken psychostimulant and the occurrence of overweight and obesity. Conclusions: The prevalence of overweight and obesity in the group of ADHD children and adolescents varies depending on the choice of diagnostic criteria. At the same time, it is significantly more frequent than in the general population. We suggest that future studies should give a clear rationale for the selection of cutoff points to minimize errors that could confound data analysis and interpretation.

Impact of CNS Stimulants for Attention-Deficit/Hyperactivity Disorder on Growth: Epidemiology and Approaches to Management in Children and Adolescents

Central nervous system stimulants are established treatments for pediatric attention-deficit/hyperactivity disorder with robust efficacy data. Reductions in appetite, weight, and growth velocity are some of the most common concerns regarding the long-term use of central nervous system stimulants in developing children. They are associated with suppression of weight and body mass index in childhood. However, both weight and body mass index often progressively increase over adolescence at rates faster than those seen in non-attention-deficit/hyperactivity disorder youth to the degree that attention-deficit/hyperactivity disorder is associated with elevated body mass index by the end of adolescence regardless of medication use. The capacity of central nervous system stimulants to slow growth was identified 50 years ago. Recent work has established that the growth deficits accumulate during the first 2 years of use and may persist provided medication is used. Early initiation coupled with persistent use through adolescence is most likely to be associated with clinical impactful growth suppression. There has been limited formal investigation of treatments for stimulant-associated reductions in weight and height. The most robust evidence exists for drug holidays improving weight gain. Observational studies suggest that limiting lifetime exposure or discontinuing medication is associated with greater adult height. Additional research is needed to identify the causal mechanisms driving the observed slowing in growth as well as the identification of predictors of clinically impactful growth suppression.

Evidence-based pharmacological treatment options for ADHD in children and adolescents

Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsivity, causing functional impairment. Its prevalence lies at approximately 5% in children and adolescents and at approximately 2.5% in adults. The disorder follows a multifactorial etiology and shows a high heritability. Patients show a high interindividual and intraindividual variability of symptoms, with executive deficits in several cognitive domains. Overall, ADHD is associated with high rates of psychiatric comorbidities, and insufficient treatment is linked to adverse long-term outcomes. Current clinical guidelines recommend an individualized multimodal treatment approach including psychoeducation, pharmacological interventions, and non-pharmacological interventions. Available medications include stimulants (methylphenidate, amphetamines) and non-stimulants (atomoxetine, guanfacine, clonidine). While available pharmacological treatment options for ADHD show relatively large effect sizes (in short-term trials) and overall good tolerability, there is still a need for improvement of current pharmacotherapeutic strategies and for the development of novel medications. This review summarizes available pharmacological treatment options for ADHD in children and adolescents, identifies current issues in research and evidence gaps, and provides an overview of ongoing efforts to develop new medications for the treatment of ADHD in children and adolescents by means of a systematic cross-sectional analysis of the clinical trials registry www.clinicaltrials.gov.

ADHD and Drug Holidays: Effects on Anthropometric Changes during Methylpenidate Treatment

OBJECTIVES

The current study evaluated the long-term effects of methylphenidate (MPH) discontinuation on growth parameters in Turkish children and adolescents with attention-deficit/hyperactivity disorder (ADHD).

EXPERIMENTAL DESIGN

432 children and adolescents (aged 6-18 years) with ADHD receiving MPH for at least 1 year between March 2012 and January 2019 were included in a retrospective cohort study. We analyzed weight, height, and body mass index (BMI) standard deviation z scores (SDS) of groups that either did (ADHD-C) or did not (ADHD-DC) discontinue MPH. Growth parameters were converted to z scores as normative values for the Turkish population to compare the measurements at baseline and the last follow-up visit by using the paired sample t-test.

PRINCIPAL OBSERVATIONS

In patients from the ADHD-C group, statistically significant negative correlations were found between age at starting MPH and differences in weight and height SDS between baseline and follow-up. Children had a greater reduction in weight and height compared to adolescents. When we evaluated the differences in pre-and post-treatment growth factors, we found no significant differences between the groups in terms of growth parameters.

CONCLUSIONS

Our data showed that chronic use of MPH was likely responsible for changes in height and weight parameters.

Pharmacotherapy for Preschool Children with Attention Deficit Hyperactivity Disorder (ADHD): Current Status and Future Directions

In this review, we consider issues relating to the pharmacological treatment of young children with attention deficit hyperactivity disorder (ADHD). ADHD in preschool-age children has a profound impact on psychosocial function and developmental trajectory. Clinical studies on pharmacotherapies for ADHD in young children have expanded rapidly in the past 2 decades, providing some evidence of efficacy for both psychostimulant and non-psychostimulant medications. However, preschool children may be more susceptible to adverse effects of medications, including growth reduction and cardiovascular side effects. Many questions remain regarding the long-term safety and effectiveness of these interventions; thus more research is needed to help clinicians evaluate the risk-benefit ratio for preschoolers with ADHD. As this body of knowledge grows, providers should consider the level of impairment caused by current symptoms in the risk-benefit analysis. Families should be educated not just about potential effects of medication but known complications of untreated ADHD; parents will likely not fully appreciate the long-term psychological effects of chronic behavioral problems and underachievement on a young child. A blanket "wait and see" approach should be avoided, in order to prevent a permanent loss of self-esteem and motivation that may affect some children throughout their lifespan.

Height, weight, and cardiovascular effects of stimulants on children with brain tumors

INTRODUCTION

Children with brain tumors may develop inattention, slow processing, and hypersomnia. Stimulant medications improve these problems, but their effect on growth, heart rate, and blood pressure (BP) are inadequately explored.

PROCEDURE

We retrospectively studied children with brain tumors treated at our institution that had data available for 1 year pre and 2 years on stimulant treatment. Tumor location, gender, radiation treatment (RT), age at RT, drug type, and hormone therapy were variables of interest.

RESULTS

We identified 65 children (35 males) that fulfilled eligibility criteria. Focal RT was utilized in 58; 11 additionally had whole brain RT; and seven received no RT. Thirty were treated for hypersomnia and inattention, eight for hypersomnia alone, and rest for inattention. Modafinil was the first drug in 18 (27.7%), and methylphenidate in the others. Forty-seven (72.3%), 45 (69.2%), and 49 (75.4%) were on thyroxine, cortisone, and growth hormones, respectively. There was no difference in pre- and post-stimulant body mass index (BMI), heart rate, and BP. There was also no difference between modafinil and methylphenidate groups. Rate of height acquisition slowed on stimulants (P = .0096). Thyroxine treatment correlated with increase in BMI after stimulants (P = .04). Younger age (P = .0003) and higher prestimulant BMI (P = .0063) correlated with increased heart rate on stimulants, while higher age at RT (P =.016) correlated with elevated systolic BP on stimulants. No associations were found with height acquisition and diastolic BP.

CONCLUSION

Stimulants are well tolerated by children with brain tumors that are appropriately managed for endocrine deficiencies, but may reduce the trajectory of height attainment.

Intentional Discontinuation of Psychostimulants Used to Treat ADHD in Youth: A Review and Analysis

Objectives: This paper reviews the literature on intentional discontinuation of psychostimulants in ADHD to summarize what is known about clinical course of controlled discontinuation and guide practitioners who are considering stopping these medications for youth with ADHD. Methods: A systematic search was executed in Cochrane CENTRAL, EMBASE, Psychinfo, and MEDLINE databases to identify all articles that addressed the topic of deprescribing of psychotropic medications in children and adolescents. Keywords and search strings were developed using "PICO" framework, involving Population of interest (<18 y.o.), Intervention ("discontinuation," "deprescribing," and synonyms), Comparator (continuation of specific medications), and Outcomes. Ten reviewers conducted the initial screen via a single reviewer system. Articles that met a set of three inclusionary criteria were selected for full text review and identification as specific to discontinuation of stimulants in ADHD. Results: The literature review identified 35 articles specifically addressing intentional deprescribing, discontinuation, tapering, or withdrawal of stimulants for children and adolescents with ADHD. In addition to providing broad support for the efficacy of stimulants to treat ADHD and reduce negative outcomes, there is a distinct population of children and adolescents with ADHD who do not relapse or deteriorate when taken off medications for ADHD. The majority of articles addressed either the re-emergence of ADHD symptoms or side effects, both desired and adverse, following discontinuation of stimulants. While confirming the ability of stimulants to treat ADHD in youth, our results support periodic consideration of trials of stopping medications to determine continued need. Conclusions: This systematic review summarizes the literature on deprescribing stimulants for ADHD in children and adolescents. Further research is needed to determine the optimal duration of treatment, identify patients that may benefit from medication discontinuation, and inform evidence-based guidelines for discontinuation when appropriate. More research is needed to understand and define the subgroup of youth who may succeed with stimulant discontinuation.

Elements of the New Conversation

These comments include established behavioral treatment preceding and augmenting stimulant use to prevent or reduce dosing, nutritional approaches with placebo-controlled evidence, and possible effects of stimulant on micronutrient levels.

Reviewing the role of emerging therapies in the ADHD armamentarium

Introduction: Attention-deficit/hyperactivity disorder (ADHD) is a common neurobehavioral disorder that can be treated with both pharmacologic and nonpharmacologic modalities. Effective drug treatments for ADHD have been available for more than six decades. However, initial treatments had limitations in duration of effect, need for multiple daily doses, requirement for patients to swallow intact tablets, adverse effects and risk for abuse and diversion. During the past 20 years, more than two dozen stimulant and nonstimulant drugs have been developed. Nonetheless, there remain unmet needs in the treatment of ADHD.Areas covered: New stimulant and nonstimulant formulations in development are reviewed with emphasis on drugs in phase II and III trials. Efficacy, mechanism of action and adverse effect data are described where available. Abuse liability studies are described for abuse-deterrent formulations in development.Expert opinion: The review found a robust pipeline of stimulants and nonstimulants. Medications in development are formulated to optimize onset and duration of effect, alter the time of administration, obviate the need to swallow whole capsules or tablets and to deter abuse. While each of these formulations may fill a unique niche, these incremental improvements based on new drug delivery technologies may lead to very significant clinical effects.

Role of Oxidative Stress and Neuroinflammation in Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder of childhood. Although abnormalities in several brain regions and disturbances of the catecholaminergic pathway have been demonstrated, the pathophysiology of ADHD is not completely understood, but as a multifactorial disorder, has been associated with an increase in oxidative stress and neuroinflammation. This review presents an overview of factors that increase oxidative stress and neuroinflammation. The imbalance between oxidants and antioxidants and also the treatment with medications are two factors that can increase oxidative damage, whereas the comorbidity between ADHD and inflammatory disorders, altered immune response, genetic and environmental associations, and polymorphisms in inflammatory-related genes can increase neuroinflammation. Evidence of an association with these factors has become valuable for research on ADHD. Such evidence opens up new intervention routes for the use of natural products as antioxidants that could have potential as a treatment against oxidative stress and neuroinflammation in ADHD.

Editorial: Time for a New Conversation on Stimulant Use

Psychostimulants are one of the safest and most efficacious pharmacological interventions for a psychiatric disorder. In 1999, the groundbreaking Multimodal Treatment of Attention-Deficit/Hyperactivity Disorder (MTA) Study set the standard of care for long-term treatment for children with attention-deficit/hyperactivity disorder (ADHD).¹ Since then, stimulant use has increased substantially around the world.² Because ADHD is a chronic condition, guidelines recommend re-evaluating the continued use of stimulant medications over many years to assess symptom relief and associated poor academic, social and work-life functioning.³ Although few long-term adverse effects have been identified, growth suppression was documented in early adulthood in the MTA cohort, with the stimulant-treated group showing an average height decrement from the untreated group of 2.55 cm or 1.00 inch.⁴ In the current issue of JAACAP, Greenhill et al. build on this earlier report.⁵ They compare growth trajectories for the self-selected ADHD stimulant medication groups and a normative comparison group. The study demonstrates differences in the shape of growth trajectories, especially during puberty, and finds that a greater total lifetime dose of stimulants is associated with increased height suppression and, not previously described, greater gain in weight and body mass index (BMI).⁵ In young adulthood, consistent stimulant users were shorter than negligible users by an estimated 4.06 cm or 1.60 inches and heavier by an estimated 4.50 kg or 9.95 pounds. The clinical implications of these findings may be significant, and certainly call for replication, funded by sources other than pharmaceutical companies. Our conversations with parents, children, and youths about the risks of long-term stimulant use should continue to mention height suppression but now include weight gain. The evidence provided suggests that the negative impact may be ameliorated through limiting total lifetime dose of stimulant medication, especially at times of rapid growth such as puberty. In view of these data, the search for evidence-based nonmedication interventions ought to intensify. Future research should be geared toward treatment goals not based solely on ADHD symptom relief but should also target overall functioning and quality of life.

Attention-deficit hyperactivity disorder

Attention-deficit hyperactivity disorder (ADHD), like other psychiatric disorders, represents an evolving construct that has been refined and developed over the past several decades in response to research into its clinical nature and structure. The clinical presentation and course of the disorder have been extensively characterised. Efficacious medication-based treatments are available and widely used, often alongside complementary psychosocial approaches. However, their effectiveness has been questioned because they might not address the broader clinical needs of many individuals with ADHD, especially over the longer term. Non-pharmacological approaches to treatment have proven less effective than previously thought, whereas scientific and clinical studies are starting to fundamentally challenge current conceptions of the causes of ADHD in ways that might have the potential to alter clinical approaches in the future. In view of this, we first provide an account of the diagnosis, epidemiology, and treatment of ADHD from the perspective of both the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the eleventh edition of the International Classification of Diseases. Second, we review the progress in our understanding of the causes and pathophysiology of ADHD on the basis of science over the past decade or so. Finally, using these discoveries, we explore some of the key challenges to both the current models and the treatment of ADHD, and the ways in which these findings can promote new perspectives.