Diagnosis and Treatment Options for Preschoolers with Attention-Deficit/Hyperactivity Disorder

The Utility of a Novel Neuropsychological Measurement to Analyze Event-Related Attentional Behaviors among Young Children with Attention Deficit Hyperactivity Disorder-a Pilot Study

OBJECTIVE

The identification and diagnosis of children with attention deficit hyperactivity disorder (ADHD) traits is challenging during the preschool stage. Neuropsychological measures may be useful in early assessments. Furthermore, analysis of event-related behavior appears to be an unmet need for clinical treatment planning. Conners' Kiddie Continuous Performance Test (K-CPT) is the most popular well-established neuropsychological measurement but lacks event markers to clarify the heterogeneous behaviors among children. This study utilized a novel commercially available neuropsychological measure, the ΣCOG, which was more game-like and provided definite event markers of individual trial in the test.

METHODS

Thirty-three older preschool children (14 were diagnosed with ADHD, mean age: 66.21 ± 5.48 months; 19 demonstrated typical development, mean age: 61.16 ± 8.11 months) were enrolled and underwent comprehensive medical and developmental evaluations. All participants underwent 2 versions of neuropsychological measures, including the K-CPT, Second Edition (K-CPT 2) and the ΣCOG, within a short interval.

RESULTS

The study indicated the omissions and response time scores measured in this novel system correlated with clinical measurement of the behavioral scales in all participants and in the group with ADHD; additionally, associations with the traditional K-CPT 2 were observed in commissions and response time scores. Furthermore, this system provided a within-task behavioral analysis that identified the group differences in the specific trial regarding omission and commission errors.

CONCLUSIONS

This innovative system is clinically feasible and can be further used as an alternative to the K-CPT 2 especially in research by revealing within-task event-related information analysis.

Topical review: sleep regulation as a novel target for treating preschool-aged children with attention-deficit/hyperactivity disorder symptoms

OBJECTIVE

Elevated attention-deficit/hyperactivity disorder (ADHD) symptoms in preschoolers are a risk factor for poorer psychiatric health, cognitive deficits, and social and academic impairment across the lifespan. The first-line treatment for these preschoolers, behavioral parent training (BPT), reduces children's disruptive behaviors and parenting stress, yet its impact on core ADHD symptoms is inconsistent. Early interventions targeting biological mechanisms linked to core ADHD pathophysiology are critically needed.

METHODS

This topical review explores sleep dysregulation as a potential key target for early intervention for ADHD symptoms among preschoolers.

RESULTS

Sleep dysregulation is common in school-aged children with ADHD, and treating sleep improves core ADHD symptoms in older children. Cross-sectional and prospective research with preschoolers offers compelling evidence that sleep dysregulation and ADHD symptoms are closely linked over the course of early development. BPT and behavioral sleep medicine (BSM) interventions share an underlying theoretical framework and could be streamlined to target sleep in addition to daytime behaviors.

CONCLUSIONS

Novel early interventions targeting underlying biological mechanisms linked to core ADHD pathophysiology are critically needed to improve the trajectories of ADHD symptoms, comorbidity, and functional deficits for preschoolers with elevated ADHD symptoms. Sleep regulation is a promising mechanistic treatment target for this population, and future interventions may draw from the shared behavioral principles of BPT and BSM to target behaviors across the 24-hr period and employ scalable formats to optimize the number of families who can benefit from parent-based interventions targeting ADHD symptoms and sleep in early development.

A Recent Advance in the Diagnosis, Treatment, and Vaccine Development for Human Schistosomiasis

Schistosomiasis, which affects a large number of people worldwide, is among the most overlooked parasitic diseases. The disease is mainly prevalent in sub-Saharan Africa, southeast Asian countries, and South America due to the lack of adequate sanitation. The disease is mainly associated with poor hygiene, sanitation, and contaminated water, so it is also known as a disease of poverty. Three Schistosoma species (S. mansoni, S. japonicum, and S. haematobium) cause significant human infections. Co-infections with Schistosoma and other parasites are widely common. All these parasites may cause intestinal or urogenital schistosomiasis, where the disease may be categorized into the acute, sensitized, and chronic phases. The disease is more prevalent among school children, which may cause anemia and reduce development. Chronic infections frequently cause significant liver, intestinal, and bladder damage. Women exposed to contaminated water while performing normal duties like washing clothes might acquire urogenital schistosomiasis (UGS), which can cause tissue damage and raise the risk of blood-borne disease transmission, including human immunodeficiency virus (HIV) transmission. Praziquantel (PZQ) is the World Health Organization (WHO)-prescribed treatment for individuals who are known to be infected, but it does not prevent further re-infections with larval worms. Vaccine development and new molecular-based diagnosis techniques have promised to be a reliable approach to the diagnosis and prevention of schistosomiasis. The current review emphasizes the recent advancement in the diagnosis of schistosomiasis by molecular techniques and the treatment of schistosomiasis by combined and alternative regimes of drugs. Moreover, this review has also focused on the recent outbreak of schistosomiasis, the development of vaccines, and their clinical trials.

Electrophysiological functional connectivity and complexity reflecting cognitive processing speed heterogeneity in young children with ADHD

Early intervention is imperative for young children with attention-deficit/hyperactivity disorder (ADHD) who manifest heterogeneous neurocognitive deficits. The study investigated the functional connectivity and complexity of brain activity among young children with ADHD exhibiting a fast cognitive processing speed (ADHD-F, n = 26), with ADHD exhibiting a slow cognitive processing speed (ADHD-S, n = 17), and typically developing children (n = 35) using wireless electroencephalography (EEG) during rest and task conditions. During rest, compared with the typically developing group, the ADHD-F group displayed lower long-range intra-hemispheric connectivity, while the ADHD-S group had lower frontal beta inter-hemispheric connectivity. During task performance, the ADHD-S group displayed lower frontal beta inter-hemispheric connectivity than the typically developing group. The ADHD-S group had lower frontal inter-hemispheric connectivity in broader frequency bands than the ADHD-F group, indicating ADHD heterogeneity in mental processing speed. Regarding complexity, the ADHD-S group tended to show lower frontal entropy estimators than the typically developing group during the task condition. These findings suggest that the EEG profile of brain connectivity and complexity can aid the early clinical diagnosis of ADHD, support subgrouping young children with ADHD based on cognitive processing speed heterogeneity, and may contain specific novel neural biomarkers for early intervention planning.

Growing evidence of pharmacotherapy effectiveness in managing attention-deficit/hyperactivity disorder in young children with or without autism spectrum disorder: a minireview

Many children with autism spectrum disorder (ASD) also have attention-deficit/hyperactivity disorder (ADHD). ADHD in children is associated with increased risk of negative outcomes, and early intervention is critical. Current guidelines recommend psychosocial interventions such as behavioral training as the first line of therapy in managing ADHD symptoms in children with or without ASD. Where symptoms are refractory to these interventions, medications such as stimulants, α2-adrenergic agonist inhibitors, selective norepinephrine reuptake inhibitors, and second-generation antipsychotics are recommended. However, these pharmacotherapies do not have regulatory approval for use in children of preschool age, and evidence on their safety and efficacy in this population has historically been very limited. Since publication of the current guidelines in 2020, several new randomized controlled trials and real-world studies have been published that have investigated the efficacy and tolerability of these medications in preschool children with ADHD, with or without comorbid ASD. Here, we provide a review of the key findings of these studies, which suggest that there is growing evidence to support the use of pharmacological interventions in the management of ADHD in preschool children with comorbid ASD.

Practice Pearls for Stimulant Treatment of Attention-Deficit/Hyperactivity Disorder in Youth

Over half of youth with attention-deficit/hyperactivity disorder (ADHD) have co-occurring psychiatric or medical conditions that present treatment challenges. Stimulants are the most effective pharmacologic treatment of ADHD for preschoolers to adults but questions about safety with co-occurring conditions frequently arise. In addition, stigma surrounding diagnosis and treatment can negatively impact care. This manuscript presents evidence-based practice pearls to guide treatment decisions for youth with ADHD and common coexisting psychiatric and medical conditions. Recommendations address specific stimulant adverse effects (i.e., anxiety, cardiac, growth, mania, psychosis) along with management strategies. Pearls were developed for the most common clinical questions, controversial topics, or therapeutic issues that may not be widely known. The goals of this manuscript are to: 1) provide a detailed resource for interprofessional teams regarding stimulant use in youth with ADHD, 2) improve therapeutic outcomes for youth with ADHD and co-occurring psychiatric and/or medical conditions through evidence-based recommendations, and 3) decrease stigma associated with stimulant use through education.

Parent experiences of their children's diagnosis with autism, attention deficit hyperactivity disorder, or both conditions

Purpose: A comparison of parents' experiences of getting a diagnosis for their child with autism, attention deficit hyperactivity disorder (ADHD) and both diagnoses can inform our understanding of common and unique themes across these neurodevelopmental conditions. Method: A quantitative and qualitative online anonymous survey of 288 New Zealand parents of children diagnosed with autism (n = 111), ADHD (n = 93), or both conditions (n = 84) was conducted. Open-ended questions were analysed using reflexive thematic analysis. Results: Parents described an adversarial diagnosis and support system where seemingly arbitrary criteria and thresholds were applied. Key themes specific to the different diagnostic groups were also identified. Conclusions: Common themes of parents' experience across the different neurodevelopmental conditions highlight the need for changes to the diagnostic process.

Efficacy of Cognitive Behavioral Therapy and Methylphenidate in the Treatment of Attention Deficit Hyperactivity Disorder in Children and Adolescents: A Systematic Review

The treatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents can be challenging and involve a combination of pharmacologic and non-pharmacological approaches. Using recent literature, we aim to identify the effectiveness of cognitive behavioral therapy (CBT) and methylphenidate (MPH) in reducing the symptoms and improving the quality of life. The investigators conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Investigators independently conducted a routine search on PubMed and Google Scholar for articles published within the last five years through July 30, 2022. Fourteen studies were identified as generally good quality but with some limitations. The final analysis included 2098 patients with an age range of three to eighteen. Nine studies reporting the efficacy of MPH in children, adolescents, or both had different formulations and doses. Six studies documenting the effectiveness of CBT had varying sessions, duration per therapy, modality of administration, and participants. The diagnostic assessment measures showed that the parent symptom rating was the highest and appeared in 11 studies, reflecting the burden on the family. In addition, a structured-self-rated questionnaire rating appeared in eight studies, and two diagnostic assessment measures, teacher symptom rating and investigators, appeared in six. The studies demonstrated significant reductions in the primary symptoms of ADHD at assessment, which led to improved behavioral and functional status with a reduced impact on family and society. Further trials are needed to understand the benefits of CBT and MPH when combined to reduce psychiatry co-morbidities and improve learning and overall quality of life in the long term.

Personalization of pharmacological treatments for ADHD: Why it is advisable and possible options to achieve it

Abstract:

Attention-deficit hyperactivity disorder is a neurodevelopmental disorder diagnosed primarily in children, although it is also present in adults. Patients present inattention, impulsivity, and hyperactivity symptoms that create difficulties in their daily lives. Pharmacological treatment with stimulants or non-stimulants is used most commonly to reduce ADHD symptoms. Although generally effective and safe, pharmacological treatments have different effects among patients, including lack of response and adverse reactions. The reasons for these differences are not fully understood, but they may derive from the highly diverse etiology of ADHD. Strategies to guide optimal pharmacological treatment selection on the basis of individual patients’ physiological markers are being developed. In this review, we describe the main pharmacological ADHD treatments used and their main drawbacks. We present alternatives under study that would allow the customization of pharmacological treatments to overcome these drawbacks and achieve more reliable improvement of ADHD symptoms.

Evaluation of Attention-Deficit/Hyperactivity Disorder Medications, Externalizing Symptoms, and Suicidality in Children

IMPORTANCE

Childhood suicidality (ie, suicidal ideation or attempts) rates are increasing, and attention-deficit/hyperactivity disorder (ADHD) and externalizing symptoms are common risk factors associated with suicidality. More data are needed to describe associations of ADHD pharmacotherapy with childhood suicidality.

OBJECTIVE

To investigate the associations of ADHD pharmacotherapy with externalizing symptoms and childhood suicidality.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, cross-sectional and 1-year-longitudinal associations were examined using data (collected during 2016-2019) from the Adolescent Brain Cognitive Development (ABCD) Study, a large, diverse US sample of children aged 9 to 11 years. Data analysis was performed from November to December 2020.

EXPOSURES

Main and interaction associations of externalizing symptoms (hyperactivity ADHD symptoms, oppositional defiant, and conduct disorder symptoms) and ADHD medication treatment (methylphenidate and amphetamine derivatives, α-2-agonists, and atomoxetine) at baseline assessment.

MAIN OUTCOMES AND MEASURES

Child-reported suicidality (past and present at baseline; current at longitudinal assessment). Covariates were age, sex, race/ethnicity, parents' education, marital status, and concomitant child psychiatric pharmacotherapy (antidepressants and antipsychotics).

RESULTS

Among 11 878 children at baseline assessment (mean [SD] age, 9.9 [0.6] years; 6196 boys [52.2%]; 8805 White [74.1%]), 1006 (8.5%) were treated with ADHD medication and 1040 (8.8%) reported past or current suicidality. Externalizing symptoms (median [range], 1 [0-29] symptom count) were associated with suicidality (for a change of 1 SD in symptoms, odds ratio [OR], 1.34; 95% CI, 1.26-1.42; P < .001), as was ADHD medication treatment (OR, 1.32; 95% CI, 1.06-1.64; P = .01). ADHD medication use was associated with less suicidality in children with more externalizing symptoms (significant symptom-by-medication interaction, B = -0.250; SE = 0.086; P = .004), such that for children who were not receiving ADHD medications, there was an association between more externalizing symptoms and suicidality (for a change of 1 SD in symptoms, OR, 1.42; 95% CI, 1.33-1.52; P < .001); however, for children who were receiving ADHD medication, there was no such association (OR, 1.15; 95% CI, 0.97-1.35; P = .10). The association with medication remained even when covarying for multiple confounders, including risk and protective factors for suicidality in ABCD, and was replicated in 1-year longitudinal follow-up. Sensitivity analyses matching participants with high numbers of externalizing symptoms taking and not taking ADHD medication treatment confirmed its association with less suicidality.

CONCLUSIONS AND RELEVANCE

These findings suggest that ADHD medication treatment is associated with less suicidality in children with substantial externalizing symptoms and may be used to inform childhood suicide prevention strategies.

First-Time Users of ADHD Medication Among Children and Adolescents in Germany: An Evaluation of Adherence to Prescribing Guidelines Based on Claims Data

Background: Drug utilization studies based on real-world data are vital for the identification of potentially needed improvements to rational prescribing. This is particularly important for the pharmacological treatment of children and adolescents with attention-deficit hyperactivity disorder (ADHD) due to the associated potential side effects and the frequent use. Whereas prevalent use is well-characterized, studies on first-time use of ADHD medication are scarce. This study aimed to evaluate off-label prescribing in first-time users of ADHD medication among children and adolescents in Germany based on three criteria: (i) lack of a documented ADHD diagnosis; (ii) first-time pharmacological treatment with a second-line drug; and (iii) patient age below 6 years. Methods: Based on German claims data, we included children and adolescents aged 0-17 years with a first-time dispensation of any ADHD medication in the period 2015-2017. These first-time users were characterized with regard to sex, age, specialty of the prescribing physician, documentation of an ADHD diagnosis, psychiatric hospitalization, psychiatric comorbidities, and history of other psychopharmacological drugs at first-time use. Results: The study population comprised 18,703 pediatric first-time users of ADHD medication. Of these, 9.8% had no documented ADHD diagnosis. Most of the ADHD drug users received first-line ADHD pharmacotherapy (methylphenidate, atomoxetine), whereas 2.6% were prescribed second-line ADHD medication (lisdexamfetamine, guanfacine, dexamfetamine, multiple ADHD drugs) as first drug. Overall, 1.2% of first-time users were aged below 6 years. A total of 12.7% of the study population met any off-label criterion. Conclusions: About 13% of pediatric first-time users of ADHD medication in Germany received an off-label pharmacotherapy at first-time use. Prescribing ADHD medication without a confirmed ADHD diagnosis was the most common of the three assessed off-label criteria. Off-label prescribing regarding drug choice and age of patients only occurred in a small percentage of initial pharmacological ADHD treatment. Our results suggest the need for improvement in rational prescribing, especially with regard to diagnostic requirements.