Stimulant medication for the child with attention-deficit/hyperactivity disorder

Stereoacuity, Fusional Vergence Amplitudes, and Refractive Errors Prior to Treatment in Patients with Attention-Deficit Hyperactivity Disorder

Objectives:

To evaluate stereoacuity, fusional vergence amplitudes, and refractive errors in patients with attention-deficit hyperactivity disorder (ADHD).

Materials and Methods:

Twenty-three patients who were newly diagnosed as having ADHD and had not started medication, and 48 children without ADHD were included. Retrospective data analysis of comprehensive eye examination, stereoacuity, and fusional vergence amplitudes of the patients were performed.

Results:

The mean age at ADHD diagnosis was 10.68±2.34 (7-16) years in the ADHD group (14 male, 9 female) and 12.23±2.16 (7-15) years in the control group (25 male, 23 female) patients (p=0.605). The mean stereoacuity was 142.14±152.65 (15-480) sec/arc in patients with ADHD and 46.3±44.11 (15-240) sec/arc in the control group (p<0.001). For ADHD patients, the mean convergence and divergence amplitudes at distance were 19.87±8.40 (6 to 38) prism diopter (PD) and -9.09±-4.34 (-4 to -25) PD, and 37.30±12.81 (14 to 70) PD and -13.13±-3.45 (-4 to -20) PD at near, respectively. The mean cycloplegic spherical equivalent was 1.06±1.13 (-1 to 4.63) diopter in ADHD patients, with 6 patients having significant refractive errors (hyperopia in 4 patients, astigmatism in 2 patients). There were no significant differences between groups in terms of spherical equivalents (p=0.358) or convergence and divergence amplitudes at distance (p=0.289 and p=0.492, respectively) or near (p=0.452 and p=0.127, respectively).

Conclusion:

Fusional vergence amplitudes did not present significant difference, while the mean value of stereoacuity was significantly lower in newly diagnosed ADHD patients prior to treatment.

Significance of Dopaminergic Gene Variants in the Male Biasness of ADHD

OBJECTIVE

ADHD is frequently detected in boys though there is no established cause. One possibility is that genes predisposing to ADHD have sexually dimorphic effects. With an aim to find out the reason for this male biasness, contribution of 14 functional polymorphisms was investigated in ADHD subjects.

METHOD

Genomic DNA of probands, their parents, and ethnically matched controls was subjected to analysis of single-nucleotide polymorphisms and variable number of tandem repeats (VNTRs).

RESULTS

Case-control analysis revealed significant higher occurrence of DAT1 intron 8 VNTR "5R" allele ( p = .028), DBH rs1108580 "A" allele ( p = .027), and MAOA-u VNTR-rs6323 3R-T haplotype ( p = .007) in male probands. Family-based analysis showed significant preferential transmission of Dopamine receptor D4 exon 3 VNTR-rs1800955 7R-T haplotype from parents to male probands ( p = .008). Interaction between DBH gene variants and low enzymatic activity was also noticed, especially in male probands.

CONCLUSION

Data obtained may partly answer the male biasness of ADHD.

Electroencephalographic alpha reactivity on opening the eyes in children with attention-deficit hyperactivity disorder

The quantification of differences in alpha electroencephalograph (EEG) activity between the eyes-closed and eyes-open resting conditions could be used as a measure of resting state arousal. The objective of this study was to evaluate the contribution of EEG alpha reactivity on opening the eyes, to the neurophysiology of children with attention-deficit hyperactivity disorder (ADHD). Thirty-eight children with ADHD were assessed using quantitative EEG (qEEG) analysis of absolute band power at rest, with eyes open and closed. Alpha reactivity index was calculated on opening the eyes, defined from the relationship between the absolute powers in the respective bands in the periods with the eyes open and closed. EEG data of 38 sex- and age-matched controls, with no neurological or psychiatric problems, were collected for comparison. There was a significant reduction in absolute alpha power at all electrodes for both ADHD and control groups with eyes open, indicating an increase in the arousal level. However, the alpha reactivity index was greater, corresponding to less reactivity, in the frontal regions of the children with ADHD (P < .01). Such a finding suggests alterations in arousal mechanisms in ADHD. This research suggests that alpha reactivity on opening the eyes, allied with other variables from the qEEG, may improve diagnostic accuracy in ADHD.

The efficacy of neurofeedback in the management of children with attention deficit/hyperactivity disorder

Attention deficit/hyperactivity disorder (ADHD) is a behavioural disorder characterized by an inappropriate level of inattention with or without impulsivity or overactivity. The estimated prevalence of ADHD is 7% to 10% in boys and 3% in girls aged four to 11 years. The higher prevalence in boys is believed to be the result of a referral bias because boys with ADHD are more disruptive and aggressive, and, therefore, more likely to be referred to specialty clinics. ADHD is caused by a combination of biological - often genetically determined neurochemical disturbances - and environmental disadvantages that are associated with learning difficulties, behavioural problems and social rejection. The identification and treatment of children with ADHD are essential in preventing or at least minimizing the serious complications associated with this disorder. Stimulant medications are the most effective means of symptomatic control of ADHD symptoms, and the safety and efficacy of these medications is well established in the literature. Despite the known efficacy of stimulant medications, alternatives are often sought by parents of children with ADHD. A number of alternative and controversial treatments for ADHD are available, including dietary management, nutritional supplementation, vision therapy, hypnotherapy, guided imagery, relaxation training and electroencephalogram (EEG) neurofeedback. Published well controlled scientific studies either to support or refute the effectiveness of EEG neurofeedback for children with ADHD are not available. At the present time, EEG neurofeedback needs to be considered as an experimental treatment, the validity of which has not yet been determined.

Long-term efficacy of methylphenidate in enhancing attention regulation, social skills, and academic abilities of childhood cancer survivors

PURPOSE

Methylphenidate (MPH) ameliorates attention problems experienced by some cancer survivors in the short term, but its long-term efficacy is unproven.

PATIENTS AND METHODS

This study investigates the long-term effectiveness of maintenance doses of MPH in survivors of childhood brain tumors (n = 35) and acute lymphoblastic leukemia (n = 33) participating in a 12-month MPH trial. Measures of attention (Conners' Continuous Performance Test [CPT], Conners' Rating Scales [CRS]), academic abilities (Wechsler Individual Achievement Test [WIAT]), social skills (Social Skills Rating System [SSRS]), and behavioral problems (Child Behavior Checklist [CBCL]) were administered at premedication baseline and at the end of the MPH trial while on medication. A cancer control group composed of patients who were not administered MPH (brain tumor = 31 and acute lymphoblastic leukemia = 23) was assessed on the same measures 12 [corrected] months apart.

RESULTS

For the MPH group, repeated measures analysis of variance revealed significant improvement in performance on a measure of sustained attention (CPT indices, P < .05); parent, teacher, and self-report ratings of attention (CRS indices, P < .05), and parent ratings of social skills or behavioral problems (SSRS and CBCL indices; P < .05). In contrast, the cancer control group only showed improvement on parent ratings of attention (Conners' Parent Rating Scale indices; P < .05) and social skills (SSRS and CBCL indices; P < .05). There was no significant improvement on the academic measure (WIAT) in either group.

CONCLUSION

Attention and behavioral benefits of MPH for childhood cancer survivors are maintained across settings over the course of a year. Although academic gains were not identified, MPH may offer benefits in academic areas not assessed.

Can we predict short-term side effects of methylphenidate immediate-release?

Objective. In children and adolescents who were prescribed immediate-release methylphenidate (MPH-IR) for the first time, we aimed to investigate the effect of gender, psychiatric co-morbidity and the baseline severity of clinical symptoms on the short-term side-effects of the medication. Method. In a clinical sample, over a period of 6 months, all MPH-naive patients with attention deficit hyperactivity disorder (ADHD) (N=90; male, n=73; female, n=17) age: 9.0±2.2 years (5-16 years)) were included. Patients were prescribed MPH-IR 10-30 mg/day (17.6±4.95). The assessment included structured measurements, including the Turgay Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV)-Based Child and Adolescent Behavior Disorders Screening and Rating Scale (T-DSM-IV-S) (parents and teachers), Conners' Teacher Rating Scale for ADHD-Short version (teachers). Parents also completed the "Barkley Stimulants' Side Effects Rating Scale" (BSSERS) at baseline and on the third, seventh and 15th days of medication. Results. Repeated measures multiple ANOVA revealed an overall significant difference in BSSERS between the baseline measures and the 15th day (P<0.01). On the 15th day, only the "loss of appetite" item severity scores increased (P=0.001), whereas the scores of "irritability", "proneness to cry", "anxiety", "nail biting" and "euphoria" items decreased significantly. In post hoc analyses, when subjects whose side effects increased and did not increase were compared, chi-square tests revealed a significant difference (P=0.029) only for the presence of co-morbidity, and no difference for the gender, age, dosage of MPH, and the baseline severity of inattentiveness and/or hyperactivity. Discussion. The only significant increase during MPH treatment was for the "loss of appetite" item on BSSERS. Our results suggest that some of the BSSERS items may represent both the ADHD symptoms and the side effects. When overall BSSERS item severity is considered, having a co-morbid diagnosis may be predictive of more severe adverse effects.

Psychosocial treatments for children with attention deficit/hyperactivity disorder

This article reviews studies examining the efficacy of behavioral interventions for the treatment of attention-deficit/hyperactivity disorder (ADHD). A specific emphasis is placed on evidence-based interventions that include parent training, classroom, academic, and peer interventions. Results indicate that school-aged children respond to behavioral interventions when they are appropriately implemented both at home and in the classroom setting. Combined treatments (behavioral management and stimulant medication) represent the gold standard in ADHD treatment and are often recommended as the first-line treatment option due to the many problems faced by children with ADHD. Diversity issues, although an important consideration in the treatment of ADHD, continue to remain an understudied area. Recommendations for future research are made pertaining to treatment sequencing with regard to behavior management as well as for subgroups of ADHD children who may respond best to specific treatments.

Factor and item-response analysis DSM-IV criteria for abuse of and dependence on cannabis, cocaine, hallucinogens, sedatives, stimulants and opioids

AIMS

This paper explored, in a population-based sample of males, the factorial structure of criteria for substance abuse and dependence, and compared qualitatively the performance of these criteria across drug categories using item-response theory (IRT).

DESIGN

Marginal maximum likelihood was used to explore the factor structure of criteria within drug classes, and a two-parameter IRT model was used to determine how the difficulty and discrimination of individual criteria differ across drug classes.

PARTICIPANTS

A total of 4234 males born from 1940 to 1974 from the population-based Virginia Twin Registry were approached to participate.

MEASUREMENTS

DSM-IV drug use, abuse and dependence criteria for cannabis, sedatives, stimulants, cocaine and opiates.

FINDINGS

For each drug class, the pattern of endorsement of individual criteria for abuse and dependence, conditioned on initiation and use, could be best explained by a single factor. There were large differences in individual item performance across substances in terms of item difficulty and discrimination. Cocaine users were more likely to have encountered legal, social, physical and psychological consequences.

CONCLUSIONS

The DSM-IV abuse and dependence criteria, within each drug class, are not distinct but best described in terms of a single underlying continuum of risk. Because individual criteria performed very differently across substances in IRT analyses, the assumption that these items are measuring equivalent levels of severity or liability with the same discrimination across different substances is unsustainable. Compared to other drugs, cocaine usage is associated with more detrimental effects and negative consequences, whereas the effects of cannabis and hallucinogens appear to be less harmful. Implications for other drug classes are discussed.

Risk factors for the development of emotional and behavioural problems in children born to drug-dependent mothers

BACKGROUND

The study of biological and psychosocial risk factors for the development of emotional and behavioural problems in children of drug-dependent mothers.

METHODS

In a sample of 52 children and drug-dependent mothers participating in a residential intervention programme emotional and behavioural problems were studied in the children by use of the Child Behaviour Checklist (CBCL). The Symptom-Checklist Revised (SCL-90-R) served to assess mental problems in the mother. Drug exposure during pregnancy, various psychosocial risk factors due to the drug-career, and educational status of the mother were assessed by maternal interview. A brief assessment of intelligence of the mother was included.

RESULTS

Among the various biological and psychosocial risk factors, maternal mental health problems, maternal educational status, and a small number of close social relationships correlated significantly with child outcome variables. Multiple regression analyses identified maternal mental health factors as the main predictors of child behaviour.

CONCLUSIONS

Assisting drug-dependent mothers in overcoming the psychosocial sequelae of drug abuse implies also assistance to the children in terms of prevention of emotional and behavioural problems.

Atomoxetine in the management of children with ADHD: effects on quality of life and school functioning

The purpose of this study was to examine in a controlled trial the effects of atomoxetine on the management of attention deficit-hyperactivity disorder (ADHD) symptoms and functional impairments at school and at home. Participants were 153 children (age 8 to 12 years) diagnosed with attention-deficit hyperactivity disorder who were randomized to double-blind treatment with either atomoxetine (n = 101) or placebo (n = 52). Findings revealed significant improvements both for parent and teacher ratings of behavior for children receiving atomoxetine therapy. Children also were reported to evidence a trend toward better response to active medication than to placebo for health-related quality of life as rated by parents. No significant effects were revealed for the teacher ratings of academic productivity. Data were interpreted to provide support for the efficacy of atomoxetine on the symptoms associated with ADHD. The effects of atomoxetine on other functional outcomes including academic performance and health-related outcomes are of interest, albeit less compelling for this particular investigation, than for the effects on overt symptom display.

The relationship between convergence insufficiency and ADHD

BACKGROUND

Children being evaluated for attention deficit hyperactivity disorder (ADHD) often have an eye exam as part of their evaluation. The symptoms of convergence insufficiency (CI) can make it difficult for a student to concentrate on extended reading and overlap with those of ADHD.

METHODS

A retrospective review of 266 patients with CI presenting to an academic pediatric ophthalmology practice was performed. All patients included were diagnosed with CI by one author (DBG) and evaluated for the diagnosis of ADHD. A computerized review was also performed looking at the converse incidence of CI in patients carrying the diagnosis of ADHD.

RESULTS

We reviewed 266 charts of patients with CI. Twenty-six patients (9.8%) were diagnosed with ADHD at some time in their clinical course. Of the patients with ADHD and CI, 20 (76.9%) were on medication for ADHD at the time of diagnosis for CI while 6 (23.1%) were either not on medication or the medication was discontinued several months before the diagnosis of CI. The review of computer records showed a 15.9% incidence of CI in the ADHD population.

CONCLUSION

We report an apparent three-fold greater incidence of ADHD among patients with CI when compared with the incidence of ADHD in the general US population (1.8-3.3%). We also note a seeming three-fold greater incidence of CI in the ADHD population. This may simply represent an association and not be a causative relationship. Until further studies are performed, however, patients diagnosed with ADHD should be evaluated to identify the small subset that may have CI -- a condition that responds well to treatment at home.

Neurofeedback: An Alternative and Efficacious Treatment for Attention Deficit Hyperactivity Disorder

Current research has shown that neurofeedback, or EEG biofeedback as it is sometimes called, is a viable alternative treatment for Attention Deficit Hyperactivity Disorder (ADHD). The aim of this article is to illustrate current treatment modalities(s), compare them to neurofeedback, and present the benefits of utilizing this method of treatment to control and potentially alleviate the symptoms of ADHD. In addition, this article examines the prevalence rates and possible etiology of ADHD, the factors associated with ADHD and brain dysfunction, the current pharmacological treatments of ADHD, Ritalin, and the potential risks and side effects. Behavior modification and cognitive behavioral treatment for ADHD is discussed as well. Lastly, a brief history of the study of neurofeedback, treatment successes and clinical benefits, comparisons to medication, and limitations are presented.

Attention deficit and hyperactivity disorder/learning disabilities (ADHD/LD): parental characterization and perception

Sixty-six parents of adolescents (mean age, 14.8 years), who attended special education classes and who were diagnosed as having attention deficit and hyperactivity disorder/learning disabilities (ADHD/LD), were interviewed. The comorbidity of the ADHD group included emotional lability and/or depression, 70%; oppositional defiant disorder (ODD), 67%; obsessive-compulsive disorder (OCD), 44%; addiction to buying, 44%; and aggressiveness, 62%. Twenty-one percent were either involved in the past or presently using drugs. Nine percent had attempted suicide. According to their parents, the main characteristic of these adolescents was low self-image. Parents enumerated five negative characteristics: impulsiveness; nervousness; angered easily ('short fused'); aggressiveness with cursing and outbursts; and impaired sociability with impoliteness.

Increasing perceptions of self-worth in preadolescents diagnosed with ADHD

PURPOSE

To test the effectiveness of a school-based, nurse-facilitated support group in increasing perceptions of scholastic competence, social acceptance, behavioral conduct, perceived athletic competence, perceived physical appearance, and perceived global self-worth in preadolescents diagnosed with attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD).

DESIGN

A quasi-experimental design with 65 preadolescents diagnosed with ADD or ADHD in an upper-middle class community in the United States.

METHODS

Participants randomly assigned to either the control or experimental group completed Harter's Self-Perception Profile for Children instrument at the beginning of the study and 4 weeks later. Students in the experimental condition participated in a school-nurse facilitated support group which met twice weekly for 4 weeks.

FINDINGS

Participants in the support group had increased scores on each of the six subscales, with significant increases on four of the subscales, including perceived social acceptance, perceived athletic competence, perceived physical appearance, and perceived global self-worth.

CONCLUSION

Participation in a school-based, nurse-led support group was positively associated with perception of self-worth in preadolescents diagnosed with ADD or ADHD.

Complementary and alternative therapies in childhood attention and hyperactivity problems

To determine the prevalence and factors associated with complementary and alternative medicine (CAM) use for childhood attention and hyperactivity problems, we surveyed parents of children referred for evaluation of attention-deficit hyperactivity disorder (ADHD). Parents indicated whether they had used CAM therapies (e.g., acupuncture, nutritional supplements) in the past year and rated how important different reasons were in making their therapy decisions. Overall, 62 of 114 (54%) parents reported using CAM, most commonly expressive therapies, vitamins, and dietary manipulation, to treat their child's attention problems. Parents who used CAM rated a "natural therapy" and "having more control over treatments" significantly more important in their choice of therapy than parents who did not use CAM. Only 11% of parents discussed using CAM with their child's physician. Because parents often use CAM to treat their child's attention and hyperactivity problems without their pediatrician's knowledge, pediatricians need to initiate discussions of CAM use with patients and families.

24-hour ambulatory blood pressure monitoring in male children receiving stimulant therapy

OBJECTIVE

To determine whether cardiac indices are altered as assessed by 24-hour ambulatory blood pressure monitoring (ABPM) in male children receiving either chronic methylphenidate or dextroamphetamine/levoamphetamine (Adderall) therapy.

METHODS

Boys 7-11 years old who were receiving methylphenidate or Adderall for a minimum of 2 months were asked to participate. Subjects wore ambulatory blood pressure monitors for 24-hour periods both off and on stimulant therapy.

RESULTS

Subjects (n = 17; 8 methylphenidate, 9 Adderall) were well matched. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate differed between off and on stimulant therapy (p < 0.05). DBP load calculated from ABPM reference data was increased significantly (9.0% +/- 5.6% on and 4.8% +/- 4.5% off therapy; p < 0.05) while subjects were taking Adderall. There was a trend toward a greater elevation in blood pressure load during awake hours and a more pronounced decrease during the asleep hours for periods on compared with off-stimulant therapy. This trend resulted in significant (p < 0.05) nocturnal dipping on-stimulant phases compared with off-stimulant therapy for both SBP and DBP (Adderall) and SBP (methylphenidate). Two subjects (1 Adderall, 1 methylphenidate) met the criteria to be considered hypertensive based both on mean awake and 24-hour blood pressure load assessments during their on-treatment period. One additional subject receiving Adderall therapy met the criteria to be considered hypertensive based on blood pressure load criteria while off therapy only. Positive correlation coefficients (p < 0.05) were found when comparing stimulant dose (mg/kg) with the percent change of mean SBP, DBP, and heart rate between off and on therapy (r = 0.56, 0.61, and 0.58, respectively).

CONCLUSIONS

These preliminary data suggest that blood pressure and heart rate appear to be altered in male patients while receiving stimulant therapy for attention-deficit hyperactivity disorder. Blood pressure and heart rate screening and monitoring during stimulant therapy to determine whether alterations become clinically significant is encouraged.

Patterns of psychotropic medication use in very young children with attention-deficit hyperactivity disorder

Psychotropic medications are increasingly used for very young children. Patterns of use in a well-described group of children 3 years and younger with a diagnostic label of attention-deficit hyperactivity disorder (ADHD) reveal both reasons to use such medications and concerns about how these medications are used. Of 223 children with ADHD, more than half (n = 127) received psychotropic medications in an idiosyncratic manner, both in the specific medication and in use over time. Almost half of the children who were medicated did not have opportunities for monitoring as often as every 3 months, despite the fact that more than half received psychotropic medications for 6 months or longer. Children with comorbid mental health conditions and chronic health conditions were at greater risk for receiving psychotropic medications. These patterns of use demonstrate a compelling need for guidance in psychopharmacological treatment of very young children.

Parent-based therapies for preschool attention-deficit/hyperactivity disorder: a randomized, controlled trial with a community sample

OBJECTIVE

To evaluate two different parent-based therapies for preschool attention-deficit/hyperactivity disorder (ADHD) in a community sample.

METHOD

Three-year-old children displaying a preschool equivalent of ADHD (n = 78) were randomly assigned to either a parent training (PT; n = 30), a parent counseling and support (PCO&S; n = 28), or a waiting-list control group (n = 20). The PT group received coaching in child management techniques. The PC&S group received nondirective support and counseling. Measures of child symptoms and mothers' well-being were taken before and after intervention and at 15 weeks follow-up.

RESULTS

ADHD symptoms were reduced (F2,74 = 11.64; p < .0001) and mothers' sense of well-being was increased by PT relative to both other groups (F2,74 = 10.32; p < .005). Fifty-three percent of children in the PT group displayed clinically significant improvement (chi 2 = 4.08; p = .048).

CONCLUSIONS

PT is a valuable treatment for preschool ADHD. PC&S had little effect on children's behavior. Constructive training in parenting strategies is an important element in the success of parent-based interventions. Psychostimulants are not a necessary component of effective treatment for many children with preschool ADHD.

Treatment of attention-deficit hyperactivity disorder

Attention-deficit hyperactivity disorder (ADHD) is a common disorder among children and adolescents with reported prevalence rates of between 3 and 10%. Recent reports suggest that a multimodal treatment approach is preferable to address many symptoms of ADHD and its associated problems for the children, the family, and the school. Stimulant medications remain the mainstay of treatment and are highly effective in more than 75% of patients. Improvement in the core symptoms of inattention, impulsivity, and hyperactivity are most noticeable. Recently approved extended release preparation of methylphenidate will allow once a day dosing. Reports of effectiveness of some non-stimulant medications such as bupropion, especially for adolescents, appear promising. A number of behavioral and psychosocial interventions can be used effectively as part of multimodal approach to address many ADHD-related problems. This article provides an update on practical information on the treatment of children and adolescents with ADHD who do not have other associated psychiatric disorders.