The effects of long-term medication on growth in children and adolescents with ADHD: an observational study of a large cohort of real-life patients

Effect of methylphenidate on height in pediatric attention-deficit hyperactivity disorder patients: a systematic review and meta-analysis

Methylphenidate (MPH), a first-line treatment for attention-deficit hyperactivity disorder (ADHD) management, has been the focus of debate for decades regarding its effect on growth. The aim of this PRISMA meta-analysis was to determine the effect of MPH on height in children/adolescents with ADHD and its predictive factors based on literature reports. Available full-text articles were systematically reviewed to identify clinical studies of pediatric ADHD patients with height Z-score (HZS) data for monotherapy MPH-treated and non-treated groups. We estimated standardized mean differences (SMDs) of HZS or its changes from baseline (ΔHZS) between groups, then identified associated factors through subgroup analyses and meta-regression. For before-after treatment studies, the paired standard errors of ΔHZS were re-estimated to demonstrate in the forest plot. Risk of bias was analyzed using the Newcastle-Ottawa Scale. Among the 29 eligible studies, 26 reported ΔHZS with self-control groups, and ΔHZS or absolute HZS were compared to other external controls in 11 studies. A significant reduction was observed between post-MHP and pre-MPH use, with high heterogeneity (SMD =  - 0.40; 95% confidence interval = [ - 0.54,  - 0.27]; I2 = 91%). The study region, ADHD subtype, and stimulant-naïve status of patients at baseline may modify the effect on HZS. Because of the high clinical heterogeneity in observational studies, clinicians should consider the negative effect of MPH on height in ADHD patients by determining whether patients fulfill appropriate high-risk criteria. Further well-designed longitudinal studies are required to better quantify this effect, especially with prolonged treatment.

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.

Effect of Methylphenidate on the onset of puberty and reproductive organ development in rats

Methylphenidate (MPH) is the first-line therapy for attention deficit hyperactivity disorder (ADHD) in children and adolescents. The aim of this study was to investigate the effects chronic MPH administration on reproductive parameters in both male and female pre-pubertal rats and reversibility of these effects. Sprague-Dawley rats were administered with 5 mg/kg MPH or saline orally from postnatal day (PND) 21 to PND60 and from PND21 to PND90. In addition, recovery groups from both sexes, in which MPH administration was stopped from PND60 to PND90 were included. Puberty onset, serum luteinizing hormone (LH), follicle stimulating hormone (FSH), testosterone and estradiol levels were determined. Histopathology of male and female reproductive organs was examined. Puberty onset was significantly early in the males (p<0.01), but late in females (p<0.05). In males, serum LH and FSH levels were similar. Testosterone levels tended to decrease in MPH-treated animals. Morphology of testes, epididymis and vas deferens was disrupted in MPH-treated animals, while it was improved in the recovery group. In females, estradiol levels decreased in MPH-treated group compared to controls, and elevated LH levels were detected in recovery group. Similar to the males, disruption in the reproductive organ histology was seen with morphological deterioration in basement membrane of the ovaries of MPH-treated groups. These adverse effects of MPH were recovered after drug cessation for 30 days. The present results demonstrate that MPH could affect the reproductive functions in both male and female rats. However, our findings also suggest that those effects are transient.

Chronic Medication Use and Factors Associated With Polypharmacy Among Outpatient Pediatric Patients

OBJECTIVE

This study aimed to determine the prevalence and predictors of chronic polypharmacy among pediatric patients in an outpatient setting.

METHODS

We conducted a review of medications dispensed to patients from an outpatient pediatric facility during a 12-month period. Patients who received chronic medications (≥30 days' supply), which contained at least 1 active pharmaceutical ingredient were included in the study. Descriptive analysis was used to determine prevalence of polypharmacy while predictive factors for polypharmacy were evaluated using logistic regression.

RESULTS

Our study included 3920 patients (median age, 9.9 years; IQR, 9.4) and 16,401 medications. The median number of chronic medications used among our study cohort was 2.0 (IQR, 1) with polypharmacy identified in 309 (7.9%) patients. Predictors for polypharmacy were age and the use of certain therapeutic class of medications. Patients 12 to <19 years old (OR, 6.95; 95% CI, 4.1-10.1) were more likely to require ≥5 concurrent medications compared with patients younger than 2 years of age. Use of calcium supplements (OR, 21.2; 95% CI, 11.3-39.6), Vitamin D analogues (OR, 14.3; 95% CI, 8.0-25.8), and systemic glucocorticoids (OR, 18.8; 95% CI, 10.7-33.2) were also highly associated with polypharmacy.

CONCLUSIONS

Adolescents and children with chronic medical conditions who require prolonged systemic glucocorticoids, calcium, and Vitamin D supplements are at higher risk of incurring long-term polypharmacy. This subgroup of pediatric patients may be more vulnerable to the occurrence of negative outcomes resulting from the use of multiple chronic medications.

Relationships between food-related behaviors, obesity, and medication use in individuals with Smith-Magenis syndrome

BACKGROUND

Smith-Magenis syndrome (SMS) is a complex neurodevelopmental disorder that includes obesity and food-seeking/satiety-related behaviors.

AIMS

This study examined associations between food-related/hyperphagic behaviors, weight, and medication use in individuals with SMS.

METHODS/PROCEDURES

Caregivers of individuals with SMS in the Parents and Researchers Interested in SMS (PRISMS) Patient Registry completed a demographic/medication questionnaire, the Hyperphagia Questionnaire for Clinical Trials, and the Food Related Problems Questionnaire.

OUTCOMES/RESULTS

Among 49 participants (M_age = 16.41 ± 12.73 years, range = 4-69 years, 55% girls/women), individuals with SMS with overweight/obesity (n = 22) had worse overall food-related problems including greater impaired satiety (p < 0.05), maladaptive eating behaviors (p < 0.05), inappropriate response (p < 0.01), and hyperphagia (p < 0.01) compared to individuals of normal/underweight (n = 27). Those taking anti-depressants/anxiolytics (n = 16) had greater maladaptive eating behaviors (p < 0.05), hyperphagic behaviors (p < 0.05), and hyperphagic severity (p < 0.05) than those not taking anti-depressants/anxiolytics (n = 33). Boys/men with SMS had greater maladaptive eating behaviors (p < 0.05), inappropriate response (p < 0.05), and hyperphagic drive (p < 0.01) than girls/women with SMS.

CONCLUSIONS/IMPLICATIONS

Maladaptive food-related behaviors were higher in individuals with SMS with overweight/obesity, taking anti-depressants/anxiolytics, or who were male. Medications in this population should be chosen with weight-related side effects in mind.

A 24-Month Effects of Methylphenidate Use on Growth in Children and Adolescents With Attention Deficit Hyperactivity Disorder

OBJECTIVE

The primary objective of this study was to investigate the effect of methylphenidate (MPH) on height, weight, and body mass index (BMI) in drug-naive children and adolescents with attention deficit hyperactivity disorder (ADHD) over 24 months. The secondary objective was to investigate whether the age of MPH initiation and sex act as risk factors for growth retardation.

METHODS

A total of 82 patients with ADHD were included. Weight, height, and BMI were measured at baseline and every 6 months up to 24 months. Weight, height, and BMI data were converted to z-scores and analyzed using two-way repeated-measures ANOVA and multiple linear regression.

RESULTS

The z-score of height, weight and BMI decreased from the baseline values. The z-scores of height were at baseline 0.002; 6 months -0.100; 12 months -0.159; 18 months -0.159; 24 months -0.186. The z-scores of weight were at baseline 0.104; 6 months -0.155; 12 months -0.256; 18 months -0.278; 24 months -0.301. Here were no age and sex differences of height, weight, and BMI.

CONCLUSION

The use of MPH was associated with attenuation of weight and height gain rates in children and adolescents with ADHD.

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.

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.

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.

Individualization of attention-deficit/hyperactivity disorder treatment: pharmacotherapy considerations by age and co-occurring conditions

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that manifests in childhood and can persist into adolescence and adulthood. Impairments associated with ADHD can impact quality of life, social interactions, and increase the risk of morbidity and mortality; however, for many patients, effective treatment can lessen these effects. Pharmacotherapy with stimulants or nonstimulants is recommended in conjunction with psychosocial therapy for most patients. Determining the optimal pharmacotherapy can be complex, and the clinician needs to consider many factors such as the patient's age, comorbidities, and lifestyle. Furthermore, the needs of the patient with ADHD will change over time, with specific challenges to consider at each stage of life. A variety of Food and Drug Administration (FDA)-approved stimulant and nonstimulant formulations are available with different modes of delivery and durations of effect. This armamentarium of ADHD medications can be used to individualize ADHD treatment for each patient's needs. This article combines current information from the literature and the first-hand experience of the authors to provide guidance on ADHD treatment options for patients of different ages and for some of the more common comorbidities.

Overdiagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: A Systematic Scoping Review

IMPORTANCE

Reported increases in attention-deficit/hyperactivity disorder (ADHD) diagnoses are accompanied by growing debate about the underlying factors. Although overdiagnosis is often suggested, no comprehensive evaluation of evidence for or against overdiagnosis has ever been undertaken and is urgently needed to enable evidence-based, patient-centered diagnosis and treatment of ADHD in contemporary health services.

OBJECTIVE

To systematically identify, appraise, and synthesize the evidence on overdiagnosis of ADHD in children and adolescents using a published 5-question framework for detecting overdiagnosis in noncancer conditions.

EVIDENCE REVIEW

This systematic scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Extension for Scoping Reviews and Joanna Briggs Methodology, including the PRISMA-ScR Checklist. MEDLINE, Embase, PsychINFO, and the Cochrane Library databases were searched for studies published in English between January 1, 1979, and August 21, 2020. Studies of children and adolescents (aged ≤18 years) with ADHD that focused on overdiagnosis plus studies that could be mapped to 1 or more framework question were included. Two researchers independently reviewed all abstracts and full-text articles, and all included studies were assessed for quality.

FINDINGS

Of the 12 267 potentially relevant studies retrieved, 334 (2.7%) were included. Of the 334 studies, 61 (18.3%) were secondary and 273 (81.7%) were primary research articles. Substantial evidence of a reservoir of ADHD was found in 104 studies, providing a potential for diagnoses to increase (question 1). Evidence that actual ADHD diagnosis had increased was found in 45 studies (question 2). Twenty-five studies showed that these additional cases may be on the milder end of the ADHD spectrum (question 3), and 83 studies showed that pharmacological treatment of ADHD was increasing (question 4). A total of 151 studies reported on outcomes of diagnosis and pharmacological treatment (question 5). However, only 5 studies evaluated the critical issue of benefits and harms among the additional, milder cases. These studies supported a hypothesis of diminishing returns in which the harms may outweigh the benefits for youths with milder symptoms.

CONCLUSIONS AND RELEVANCE

This review found evidence of ADHD overdiagnosis and overtreatment in children and adolescents. Evidence gaps remain and future research is needed, in particular research on the long-term benefits and harms of diagnosing and treating ADHD in youths with milder symptoms; therefore, practitioners should be mindful of these knowledge gaps, especially when identifying these individuals and to ensure safe and equitable practice and policy.

Evaluation of Bone Age in Children: A Mini-Review

Bone age represents a common index utilized in pediatric radiology and endocrinology departments worldwide for the definition of skeletal maturity for medical and non-medical purpose. It is defined by the age expressed in years that corresponds to the level of maturation of bones. Although several bones have been studied to better define bone age, the hand and wrist X-rays are the most used images. In fact, the images obtained by hand and wrist X-ray reflect the maturity of different types of bones of the skeletal segment evaluated. This information, associated to the characterization of the shape and changes of bone components configuration, represent an important factor of the biological maturation process of a subject. Bone age may be affected by several factors, including gender, nutrition, as well as metabolic, genetic, and social factors and either acute and chronic pathologies especially hormone alteration. As well several differences can be characterized according to the numerous standardized methods developed over the past decades. Therefore, the complete characterization of the main methods and procedure available and particularly of all their advantages and disadvantages need to be known in order to properly utilized this information for all its medical and non-medical main fields of application.

Synergistic efficacy and diminished adverse effect profile of composite treatment of several ADHD medications

Although attention-deficit/hyperactivity disorder (ADHD) is widely studied, problems regarding the adverse effect risks and non-responder problems still need to be addressed. Combination pharmacotherapy using standard dose regimens of existing medication is currently being practiced mainly to augment the therapeutic efficacy of each drug. The idea of combining different pharmacotherapies with different molecular targets to alleviate the symptoms of ADHD and its comorbidities requires scientific evidence, necessitating the investigation of their therapeutic efficacy and the mechanisms underlying the professed synergistic effects. Here, we injected male ICR mice with MK-801 to induce ADHD behavioral condition. We then modeled a "combined drug" using sub-optimal doses of methylphenidate, atomoxetine, and fluoxetine and investigated the combined treatment effects in MK-801-treated mice. No sub-optimal dose monotherapy alleviated ADHD behavioral condition in MK-801-treated mice. However, treatment with the combined drug attenuated the impaired behavior of MK-801-treated animals. Growth impediment, sleep disturbances, or risk of substance abuse were not observed in mice treated subchronically with the combined drugs. Finally, we observed that the combined ADHD drug rescued alterations in p-AKT and p-ERK1/2 levels in the prefrontal cortex and hippocampus, respectively, of MK-801-treated mice. Our results provide experimental evidence of a possible new pharmacotherapy option in ameliorating the ADHD behavioral condition without the expected adverse effects. The detailed mechanism of action underlying the synergistic therapeutic efficacy and reduced adverse reaction by combinatorial drug treatment should be investigated further in future studies.

Neurocognitive, neuropsychiatric, and neurological outcomes associated with phenylalanine hydroxylase deficiency: Assessment considerations for nurse practitioners

PURPOSE

The purpose of this article is to review literature for neurocognitive, neuropsychiatric, neurological complications associated with phenylalanine hydroxylase (PAH) deficiency. The goal is to familiarize nurse practitioners with treatment and monitoring guidelines for persons living with the disorder.

CONCLUSIONS

Appropriate treatment can maximize neurocognitive and neuropsychiatric outcomes.

PRACTICE IMPLICATIONS

Nurse practitioners can help persons with PAH deficiency through education and providing appropriate referrals and by supporting disease-specific treatment.

Long term methylphenidate exposure and growth in children and adolescents with ADHD. A systematic review and meta-analysis

BACKGROUND

Methylphenidate (MPH) is an efficacious treatment for ADHD but concerns have been raised about potential adverse effects of extended treatment on growth.

OBJECTIVES

To systematically review the literature, up to December 2018, conducting a meta-analysis of association of long-term (> six months) MPH exposure with height, weight and timing of puberty.

RESULTS

Eighteen studies (ADHD n = 4868) were included in the meta-analysis. MPH was associated with consistent statistically significant pre-post difference for both height (SMD = 0.27, 95% CI 0.16-0.38, p < 0.0001) and weight (SMD = 0.33, 95% CI 0.22-0.44, p < 0.0001) Z scores, with prominent impact on weight during the first 12 months and on height within the first 24-30 months. No significant effects of dose, formulation, age and drug-naïve condition as clinical moderators were found. Data on timing of puberty are currently limited.

CONCLUSIONS

Long-term treatment with MPH can result in reduction in height and weight. However, effect sizes are small with possible minimal clinical impact. Long-term prospective studies may help to clarify the underlying biological drivers and specific mediators and moderators.

Attention-deficit hyperactivity disorder symptomatology, binge eating disorder symptomatology, and body mass index among college students

Objective: To explore the relationship between symptoms of attention-deficit hyperactivity disorder (ADHD), symptoms of binge eating disorder, and body mass index (BMI) among students at a southern university. Participants: Two hundred seventy-seven college students. Methods: Between January 31, 2013 and March 27, 2013, participants completed the Adult ADHD Self-Report Scale (ASRS) Screener and the Binge Eating Scale (BES) in addition to permitting researchers to measure their height and weight. Results: Higher ASRS scores, higher BMIs, and lower BES scores were observed among men. Among both men and women, BES scores were positively correlated with BMI and ASRS scores; however, the correlation between ASRS and BMI was not significant. Conclusion: Binge eating disorder symptomatology was associated with increased ADHD symptomatology and a higher BMI among both men and women. Among students presenting with obesity or ADHD, screening for binge eating may assist with the identification of problematic eating behaviors.

The Effects of Methylphenidate Treatment on Child Growth in Thai Children and Adolescents with Attention-Deficit/Hyperactivity Disorder

Objectives: To determine the effects of methylphenidate treatment on child growth in Thai pediatric patients with attention-deficit/hyperactivity disorder (ADHD). Methods: The medical records of children and adolescents with ADHD, between 5 and 18 years of age, who received pharmacological treatment with methylphenidate as a sole psychiatric medication for ≥1 year between 2001 and 2018 at the Rajanagarindra Institute of Child Development, Thailand, were retrospectively reviewed. Data on anthropometric parameters and methylphenidate use were extracted. Height and weight were converted to age- and gender-corrected standard scores (z-scores) using norms from the Thai pediatric population. Changes in height and weight z-scores were assessed using a paired t-test or one-way repeated measures ANOVA with the Bonferroni correction. Results: In this retrospective observational study, 911 children and adolescents were eligible, with the mean age of 95.0 ± 19.5 months at baseline, the cumulative duration of methylphenidate treatment of 39.4 ± 23.5 months, and the average daily dosage of 14.1 ± 6.2 mg/day. Comparative analysis found no statistically significant change in height z-scores between baseline and last recorded measurement (mean difference = 0.0017, confidence interval [95% CI] = -0.0004 to 0.0038, p = 0.107), while a slight, but significant increase in weight z-scores was observed (mean difference = 0.0271, 95% CI = 0.0179-0.0362, p < 0.001). Longitudinal analysis observed that weight z-scores were significantly decreased during the first year of therapy, but regained in the second year and continued to increase in subsequent years of therapy. Conclusion: Treatment with methylphenidate in our cohort of Thai pediatric patients with ADHD was not associated with growth deficits, except for a slightly significant decrease in weight during the first year of therapy.

Methylphenidate and Reduced Overweight in Children With ADHD

Objective: The objective of this study was to investigate odds ratios of overweight/obesity in children with ADHD and to compare the change in body mass index (BMI) after initiation of methylphenidate treatment in normal versus overweight/obese children. Method: This population-based study included 724 children (<18 years), of whom 197 were girls. Odds ratios for overweight and obesity were calculated, comparing the study group with a reference group from the same area. After initiation of methylphenidate treatment, changes in BMI were assessed for up to 3 years. Results: Children with ADHD had an odds ratio of 1.87 (95% confidence interval [CI]: [1.60, 2.19]) for overweight/obesity. A decrease in BMI standard deviation score was identified 1 to 3 years into treatment. The decrease was beneficially greater in overweight/obese as compared with normal weight children-mean (SD) -0.64 (0.80) versus -0.39 (0.68); p = .001-and greater in girls. Conclusion: Medication with methylphenidate may facilitate favorable weight development in children with ADHD and overweight/obesity.

Duration of Pediatric Clinical Trials Submitted to the US Food and Drug Administration

Importance

The increasing prevalence of pediatric chronic disease has resulted in increased exposure to long-term drug therapy in children. The duration of recently completed drug trials that support approval for drug therapy in children with chronic diseases has not been systematically evaluated. Such information is a vital first step in forming safety pharmacovigilance strategies for drugs used for long-term therapy in children.

Objective

To characterize the duration of clinical trials submitted to the US Food and Drug Administration (FDA) for pediatric drug approvals, with a focus on drugs used for long-term therapy.

Design and Setting

A review was performed of all safety and efficacy clinical trials conducted under the Best Pharmaceuticals for Children Act or the Pediatric Research Equity Act and submitted to the FDA from September 1, 2007, to December 31, 2014, to support the approval of drugs frequently used for long-term therapy in children. Statistical analysis was performed from July 1, 2015, to December 31, 2017.

Main Outcomes and Measures

Maximum duration of trials submitted to support FDA approval of drugs for children.

Results

A total of 306 trials supporting 86 drugs intended for long-term use in children were eligible for the primary analysis. The drugs most commonly evaluated were for treatment of neurologic (25 [29%]), pulmonary (16 [19%]), and anti-infective (14 [16%]) indications. The median maximum trial duration by drug was 44 weeks (minimum, 1.1 week; maximum, 364 weeks). For nearly two-thirds of the drugs (52 [61%]), the maximum trial duration was less than 52 weeks. For 10 of the drugs (12%), the maximum trial duration was 3 years or more. Maximum duration of trials did not vary by therapeutic category, minimum age of enrollment, calendar year, or legislative mandate.

Conclusions and Relevance

Pediatric clinical trials designed to sufficiently investigate drug safety and efficacy to support FDA approval are of relatively limited duration. Given the potential long-term exposure of patients to these drugs, the clinical community should consider whether new approaches are needed to better understand the safety associated with long-term use of these drugs.

Impact of Central Nervous System Stimulant Medication Use on Growth in Pediatric Populations with Attention-Deficit/Hyperactivity Disorder: A Review

Central nervous system stimulants are a commonly used first-line treatment option for attention-deficit/hyperactivity disorder (ADHD). Stimulants are generally well tolerated, with anorexia and insomnia the most common adverse effects. However, there are some concerns with long-term use of stimulants, such as potential growth delay. Historically, data regarding this long-term adverse effect have been conflicting. In this article, we review the newer data surrounding the effects of central nervous system stimulants on growth parameters in children with ADHD. We conducted a literature search of the PubMed database; only articles using ADHD criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision; and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, were included to ensure the most up-to-date review of literature. Nine articles were identified for relevance and quality and are discussed in this review, describing clinical observations of height and weight of adolescent or pediatric patients receiving stimulant medications for ADHD therapy. In summary, this review points toward potential associations between duration of treatment and higher doses of stimulants with decreased weight and body mass index. Furthermore, this review demonstrates that evidence is still conflicting regarding the relationship between stimulant use and significant height decreases. Future studies with higher quality of evidence are needed to observe this potential adverse effect of stimulants in children and adolescents.

Psychostimulants: Influence on Body Mass Index and Height in a Pediatric Population with Attention-Deficit/Hyperactivity Disorder?

OBJECTIVES

Attention-deficit/hyperactivity disorder (ADHD) is often treated with psychostimulants. Psychostimulants' adverse effects on body mass index standard deviation score (BMI-sds) and height in children/adolescents with ADHD have been reported. However, literature is inconsistent, and it is unclear whether the observed effects are dosage- and/or BMI-dependent. Therefore, the aim of this retrospective observational study is to evaluate the influence of psychostimulants on BMI-sds and height-sds in a pediatric cohort with ADHD from an outpatient clinic, and to study the correlation between psychostimulant dosage and BMI-sds and height-sds change.

METHOD

Participants ≤18 years of age diagnosed with ADHD who started with psychostimulants (methylphenidate) were studied. Changes in BMI-sds and height-sds over an 18-month treatment period were assessed in subgroups according to baseline BMI-sds, gender, and age. Furthermore, correlations between BMI-sds, height-sds, and psychostimulant dose were studied.

RESULTS

In total, 298 participants [median age 9.8 years, height-sds 0.0, BMI-sds 0.5, psychostimulant dosage 0.5 (0.2-1.4) mg/kg/day] were analyzed, with an underweight, overweight, and obesity prevalence of 5%, 21%, and 7%, respectively. After 18 months of treatment a significant decline in BMI-sds (-0.4) and height-sds (-0.2) was observed. These effects were consistent in all subgroups except for no change in BMI-sds in the underweight subgroup and no change in height-sds in the overweight subgroup. Medication dosage was weakly correlated with change in BMI-sds [r = -0.3 (-0.9 to +0.5); p < 0.01] and height-sds [r = -0.2 (-0.4 to -0.1); p = 0.01].

CONCLUSION

After 18 months of psychostimulant treatment, a significant decline in BMI-sds and height-sds was observed. However, the correlation with psychostimulant dosage was weak, and the decline was not observed in all subgroups. Therefore, further studies on the etiology of BMI-change are warranted, particularly with regard to the ADHD symptoms.

Bone Age: A Handy Tool for Pediatric Providers

Pediatricians have relied on methods for determining skeletal maturation for >75 years. Bone age continues to be a valuable tool in assessing children's health. New technology for bone age determination includes computer-automated readings and assessments obtained from alternative imaging modalities. In addition, new nonclinical bone age applications are evolving, particularly pertaining to immigration and children's rights to asylum. Given the significant implications when bone ages are used in high-stake decisions, it is necessary to recognize recently described limitations in predicting accurate age in various ethnicities and diseases. Current methods of assessing skeletal maturation are derived from primarily white populations. In modern studies, researchers have explored the accuracy of bone age across various ethnicities in the United States. Researchers suggest there is evidence that indicates the bone ages obtained from current methods are less generalizable to children of other ethnicities, particularly children with African and certain Asian backgrounds. Many of the contemporary methods of bone age determination may be calibrated to individual populations and hold promise to perform better in a wider range of ethnicities, but more data are needed.

Weight, Height, and Body Mass Index in Patients with Attention-Deficit/Hyperactivity Disorder Treated with Methylphenidate

OBJECTIVE

To describe the methylphenidate (MPH) effects on weight, height, and body mass index (BMI) in a Spanish sample diagnosed with attention-deficit/hyperactivity disorder (ADHD).

METHODS

Patients (6-18 years) diagnosed with ADHD treated at our Unit with MPH in the last 10 years were included in an observational longitudinal study. Weight, height, and BMI Z scores were measured at baseline and at last follow-up.

RESULTS

Three hundred forty-two patients (mean [standard deviation] age: 10.7 [3.8] years, 80% males) were included. Mean dose was 1.25 (0.40) mg/(kg·d). After 27 (14-41) months taking MPH, weight and BMI standard deviation score (SDS) were reduced by treatment (baseline weight-SDS: 0.34 [1.22], follow-up weight-SDS: -0.06 [1.38], t-test p < 0.001; baseline BMI-SDS: 0.35 [1.10], and follow-up BMI-SDS [SDS]: -0.23 [1.08], t-test p < 0.001). In the whole sample, no differences in height before and after treatment were observed. However, considering only the group of patients who were children 6-12 years (68.6%) when starting treatment, height was slightly affected (baseline height-SDS: 0.04 [1.14], follow-up: -0.10 [1.11], p < 0.001). This effect was not observed if treatment was started during adolescence. Linear regression analysis showed that age starting MPH (B = 0.07, p = 0.003), dose (B = -0.50, p = 0.001), and duration of treatment (B = 0.07, p = 0.031) affect follow-up height.

CONCLUSION

MPH slightly decreased weight and BMI in this group of ADHD patients followed naturalistically over 2.2 years, and slightly affected height only if treatment was started before the age of 12. Girls, children who started treatment being younger or children on higher MPH doses, showed greater impact in height.

Growth perturbations from stimulant medications and inhaled corticosteroids

Stimulant medications for the treatment of attention deficit hyperactivity disorder (ADHD) and inhaled corticosteroids (ICS) for the treatment of asthma are two classes of medications that are commonly prescribed in pediatrics. Among other adverse effects of these medications, growth attenuation has long been a focus of investigation. With stimulants, growth deficits of 1-1.4 cm/year have been observed in the short term, mainly in the first 2 years of treatment, in a dose-dependent manner. Long-term studies on stimulants have reported divergent effects on growth, with many studies showing no clinically significant height deficits by adulthood. The study that followed the largest cohort of children on stimulants, however, reported an overall adult height deficit of 1.29 cm in subjects who had received stimulant medications, with mean adult height deficit of 4.7 cm among those taking the medication consistently. With ICS use, mild growth suppression is seen in the short term (particularly in the first year of therapy) with growth rates reduced by 0.4-1.5 cm/year. Available current evidence indicates that the impact of ICS use on adult height is not clinically significant, with effects limited to 1.2 cm or less. There is significant individual variability in growth suppression with ICS use, with the specific pharmacologic agent, formulation, dose exposure, age, puberty, medication adherence, and timing of administration being important modifying factors. Based on currently available evidence, the therapeutic benefits of ICS for management of asthma and stimulant medications for management of ADHD outweigh the potential risk for growth suppression. Strategies to minimize growth attenuation and other potential adverse effects of these medications include using the lowest efficacious dose, frequent assessments and dose titration. Particular vigilance is essential with concomitant use of multiple medications that can attenuate growth and to evaluate for potential adrenal insufficiency from ICS use.

A double-blind randomized pilot trial comparing computerized cognitive exercises to Tetris in adolescents with attention-deficit/hyperactivity disorder

BACKGROUND

The purpose of this trial was to examine the feasibility and efficacy of computerized cognitive exercises from Scientific Brain Training (SBT), compared to the computer game Tetris as an active placebo, in a pilot study of adolescents with attention-deficit/hyperactivity disorder (ADHD).

METHOD

Eighteen adolescents with ADHD were randomized to treatment or control intervention for 7 weeks. Outcome measures were cognitive test, symptom, and motivation questionnaires.

RESULTS

SBT and Tetris were feasible as home-based interventions, and participants' compliance was high, but participants perceived both interventions as not very interesting or helpful. There were no significant group differences on cognitive and ADHD-symptom measures after intervention. Pre-post intra-group measurement showed that the SBT had a significant beneficial effect on sustained attention, while the active placebo had significant beneficial effects on working memory, both with large effect sizes.

CONCLUSION

Although no significant differences were found between groups on any measure, there were significant intra-group changes for each group.