Uses and misuses of treatments for ADHD. The second Birgit Olsson lecture

Assessing undertreatment and overtreatment/misuse of ADHD medications in children and adolescents across continents: A systematic review and meta-analysis

A controversy exists on whether there is an over or underuse of medications for Attention-Deficit/Hyperactivity Disorder (ADHD). We conducted the first meta-analysis to estimate the rate of ADHD pharmacological treatment in both diagnosed and undiagnosed individuals. Based on a pre-registered protocol (CRD42018085233), we searched a broad set of electronic databases and grey literature. After screening 25,676 abstracts, we retained 36 studies including 104,305 subjects, from which 18 studies met our main analysis criteria. The pooled pharmacological treatment rates were 19.1 % and 0.9 % in school-age children/adolescents with and without ADHD, respectively. We estimated that for each individual using medication without a formal ADHD diagnosis, there are three patients with a formal diagnosis who might benefit from medication but do not receive it in the US. Our results indicate both overtreatment/misuse of medication in individuals without ADHD and pharmacological undertreatment in youths with the disorder. Our findings reinforce the need for public health policies improving education on ADHD and discussions on the benefits and limitations of ADHD medications.

Moderator Role of Monitoring in the Inhibitory Control of Adolescents With ADHD

Objective: The aim of this research was to analyze the role of monitoring in the causal relationship between inhibitory control and symptoms of combined ADHD. Method: It has been conducted a quantitative investigation of two phases. Results: In the first study, a moderation model was analyzed (N = 144 adolescents with combined ADHD), where monitoring was considered as a moderating variable in the causal relationship between the inhibitory control and the symptomatology of ADHD F(3, 140) = 28.03, p < .001; R² = .37. In the second study, the model through an experimental study was tested (N = 52 adolescents with and without ADHD) where it was found that adolescents with ADHD improve in their inhibitory control when they receive external support to the monitoring F(1, 50) = 21.38, p < .001, η² = .30. Conclusion: Results suggest that monitoring compensates the poor performance of inhibitory control in adolescents with ADHD, which is a contribution to the theoretical construction of ADHD and to the treatments proposed for this condition because it goes beyond the classic conception of a causality chain among the deficit of inhibitory control and ADHD symptomatology to propose a new explanation about this disorder, where neuropsychology intervention of monitoring would diminish ADHD's symptomatology impact on adolescents.

Clinical and Experimental Factors Influencing the Efficacy of Neurofeedback in ADHD: A Meta-Analysis

Meta-analyses have been extensively used to evaluate the efficacy of neurofeedback (NFB) treatment for Attention Deficit/Hyperactivity Disorder (ADHD) in children and adolescents. However, each meta-analysis published in the past decade has contradicted the methods and results from the previous one, thus making it difficult to determine a consensus of opinion on the effectiveness of NFB. This works brings continuity to the field by extending and discussing the last and much controversial meta-analysis by Cortese et al. (1). The extension comprises an update of that work including the latest control trials, which have since been published and, most importantly, offers a novel methodology. Specifically, NFB literature is characterized by a high technical and methodological heterogeneity, which partly explains the current lack of consensus on the efficacy of NFB. This work takes advantage of this by performing a Systematic Analysis of Biases (SAOB) in studies included in the previous meta-analysis. Our extended meta-analysis (k = 16 studies) confirmed the previously obtained results of effect sizes in favor of NFB efficacy as being significant when clinical scales of ADHD are rated by parents (non-blind, p-value = 0.0014), but not when they are rated by teachers (probably blind, p-value = 0.27). The effect size is significant according to both raters for the subset of studies meeting the definition of "standard NFB protocols" (parents' p-value = 0.0054; teachers' p-value = 0.043, k = 4). Following this, the SAOB performed on k = 33 trials identified three main factors that have an impact on NFB efficacy: first, a more intensive treatment, but not treatment duration, is associated with higher efficacy; second, teachers report a lower improvement compared to parents; third, using high-quality EEG equipment improves the effectiveness of the NFB treatment. The identification of biases relating to an appropriate technical implementation of NFB certainly supports the efficacy of NFB as an intervention. The data presented also suggest that the probably blind assessment of teachers may not be considered a good proxy for blind assessments, therefore stressing the need for studies with placebo-controlled intervention as well as carefully reported neuromarker changes in relation to clinical response.

Are ADHD medications under or over prescribed worldwide?: Protocol for a systematic review and meta-analysis

INTRODUCTION

Attention-Deficit/Hyperactivity Disorder (ADHD) is a common neurodevelopmental disorder, characterized by age inappropriate and impairing levels of inattention and/or hyperactivity/impulsivity. Pharmacotherapy is an important part of the ADHD multimodal treatment. The extent to which ADHD is pharmacologically over or under treated worldwide is controversial. We aimed to estimate the pooled worldwide rate of ADHD pharmacological treatment in individuals with and without the disorder.

METHOD AND ANALYSIS

We will include published or unpublished studies reporting the rates of ADHD pharmacological treatment in participants with and without ADHD of any age group. Population-based, cohort, or follow-up studies, as well as data from insurance health system and third-party reimbursements will be eligible. Searches will be performed in a large number of electronic databases, including Medline, Embase, CINAHL, Cochrane, PsycINFO, Web of Science, and Scopus. The primary outcome will be the prevalence of ADHD pharmacological treatment in individuals with ADHD and without ADHD. Two independent reviewers will perform the screening, and data extraction process. Study quality/bias will be assessed with the Newcastle-Ottawa scale by 2 independent reviewers. To test the robustness of the findings, we will perform a series of sensitivity and meta-regression analysis. Analyses will be performed with R and STATA software.

ETHICS AND DISSEMINATION

No IRB approval will be necessary. The results of this systematic review and meta-analysis will be presented at international conferences and published in peer-reviewed journals.

REGISTRATION AND STATUS

PROSPERO 2018 CRD42018085233.

Attention-Deficit/Hyperactivity Disorder in Looked-After Children: a Systematic Review of the Literature

PURPOSE OF REVIEW

To systematically review the literature on the prevalence and pharmacological treatment of ADHD in looked-after children (LAC).

RECENT FINDINGS

LAC are a very challenging population from a clinical and psychosocial standpoint, with higher mental health needs compared to non LAC. To date, no systematic review on the prevalence of ADHD, and its treatment, in LAC is available.

SUMMARY

We searched Pubmed, PsycInfo EMBASE + EMBASE CLASSIC, OVID Medline and Web of Science up to November 9 th, 2016. We found 24 papers meeting our criteria. The vast majority of the retained studies are from the USA and show rates of ADHD and of its pharmacological treatment substantially higher in LAC than those reported in national estimates. Future studies from countries other than the USA, aiming to understand the most cost-effective strategies, in the short as well as long term, to manage symptoms of ADHD in LAC are needed.

Pharmacological and non-pharmacological treatment of adults with ADHD: a meta-review

Attention-deficit/hyperactivity disorder (ADHD) is characterised by a persistent and impairing pattern of inattention and/or hyperactivity/impulsivity and it is one of the most common neuropsychiatric conditions. Evidence about interventions of adults with ADHD is growing rapidly and clinicians need a reliable summary of all the best available information in order to better inform their daily practice. We searched MEDLINE, PubMed, PsycINFO and Cochrane databases until 31 May 2016 for systematic reviews about pharmacological and non-pharmacological treatments in adults with ADHD and carried out a meta-review to address clinically relevant questions. We identified a total of 40 papers. Psychostimulants-such as methylphenidate, dexamphetamine, mixed amphetamine salts and lisdexamfetamine-and non-psychostimulants-such as atomoxetine-were the most studied agents. Overall, pharmacological treatments were significantly more efficacious than placebo (standardised mean difference (SMD) 0.45, 95% CI 0.37 to 0.52), albeit less well accepted (OR 1.18, 95% CI 1.02 to 1.36) and tolerated (OR 2.29, 95% CI 1.97 to 2.66). The effects of pharmacological treatment for individuals with co-occurring ADHD and substance use disorder are still uncertain. The evidence for the efficacy and effectiveness of non-pharmacological treatments of ADHD in adults, as well as the combination of pharmacological and non-pharmacological strategies, is only preliminary. In conclusion, while available evidence addressed mainly the efficacy and tolerability of psychostimulants and non-psychostimulants for ADHD core symptoms in the short term, we still need further empirical support for the non-pharmacological and multimodal treatments. A comprehensive evidence-informed hierarchy of ADHD drugs based on their efficacy and tolerability is not yet available but it should be the next research priority in the field.

Comparative efficacy and tolerability of pharmacological interventions for attention-deficit/hyperactivity disorder in children, adolescents and adults: protocol for a systematic review and network meta-analysis

INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD) is a major public health issue. Pharmacological treatments play an important role in the multimodal treatment of ADHD. Currently, there is a lack of up-to-date and comprehensive evidence on how available ADHD drugs compare and rank in terms of efficacy and tolerability, in children or adolescents as well as in adults. We will conduct a network meta-analysis (NMA), integrating direct and indirect comparisons from randomised controlled trials (RCTs), to rank pharmacological treatments for ADHD according to their efficacy and tolerability profiles.

METHODS AND ANALYSIS

We will search a broad range of electronic databases, including PubMed, MEDLINE, EMBASE, PsycINFO, ERIC and Web of Science, with no date or language restrictions. We will also search for unpublished studies using international clinical trial registries and contacting relevant drug companies. We will identify and include available parallel-group, cross-over and cluster randomised trials that compare methylphenidate, dexmethylphenidate, amphetamine derivatives (including lisdexamfetamine), atomoxetine, clonidine, guanfacine, bupropion or modafinil (as oral therapy) either with each other or to placebo, in children, adolescents or adults with ADHD. Primary outcomes will be efficacy (indicated by reduction in severity of ADHD core symptoms measured on a standardised scale) and tolerability (the proportion of patients who left a study early due to side effects). Secondary outcomes will be global functioning, acceptability (proportion of patients who left the study early by any cause) and changes in blood pressure and body weight. NMA will be conducted in STATA within a frequentist framework. The quality of RCTs will be evaluated using the Cochrane risk of bias tool, and the quality of the evidence will be assessed using the GRADE approach. Subgroup and sensitivity analyses will be conducted to assess the robustness of the findings.

ETHICS AND DISSEMINATION

No ethical issues are foreseen. Results from this study will be published in a peer-reviewed journal and possibly presented at relevant national and international conferences.

TRIAL REGISTRATION NUMBER

CRD42014008976.

Neurofeedback for Attention-Deficit/Hyperactivity Disorder: Meta-Analysis of Clinical and Neuropsychological Outcomes From Randomized Controlled Trials

OBJECTIVE

We performed meta-analyses of randomized controlled trials to examine the effects of neurofeedback on attention-deficit/hyperactivity disorder (ADHD) symptoms and neuropsychological deficits in children and adolescents with ADHD.

METHOD

We searched PubMed, Ovid, Web of Science, ERIC, and CINAHAL through August 30, 2015. Random-effects models were employed. Studies were evaluated with the Cochrane Risk of Bias tool.

RESULTS

We included 13 trials (520 participants with ADHD). Significant effects were found on ADHD symptoms rated by assessors most proximal to the treatment setting, that is, the least blinded outcome measure (standardized mean difference [SMD]: ADHD total symptoms = 0.35, 95% CI = 0.11-0.59; inattention = 0.36, 95% CI = 0.09-0.63; hyperactivity/impulsivity = 0.26, 95% CI = 0.08-0.43). Effects were not significant when probably blinded ratings were the outcome or in trials with active/sham controls. Results were similar when only frequency band training trials, the most common neurofeedback approach, were analyzed separately. Effects on laboratory measures of inhibition (SMD = 0.30, 95% CI = -0.10 to 0.70) and attention (SMD = 0.13, 95% CI = -0.09 to 0.36) were not significant. Only 4 studies directly assessed whether learning occurred after neurofeedback training. The risk of bias was unclear for many Cochrane Risk of Bias domains in most studies.

CONCLUSION

Evidence from well-controlled trials with probably blinded outcomes currently fails to support neurofeedback as an effective treatment for ADHD. Future efforts should focus on implementing standard neurofeedback protocols, ensuring learning, and optimizing clinically relevant transfer.