Long-term safety of stimulant medications used to treat children with ADHD

Academic Skills Groups for Middle School Children With ADHD in the Outpatient Mental Health Setting: An Open Trial

OBJECTIVE

To conduct an open trial assessing the initial efficacy of an intervention focusing on increasing skills related to academic performance (planning, organization, studying, and homework behaviors) for middle school children diagnosed with ADHD. The intervention is modeled on evidence-based interventions but designed for administration in the outpatient setting.

METHOD

Parents and their children diagnosed with ADHD attended seven weekly group sessions targeting academic, organizational, and homework skills. Parents completed the Homework Problem Checklist and Impairment Rating Scale pre- and post-treatment.

RESULTS

Following intervention, significant improvements in homework completion and management, as well as reductions in academic impairment and improvements in parent confidence and family relations, were reported.

CONCLUSION

Despite limitations including small sample size and lack of a control group, our results demonstrate initial efficacy of an academic skills intervention designed for use in the outpatient setting with middle school children diagnosed with ADHD on clinically relevant outcome measures.

Adverse reactions of Methylphenidate in children with attention deficit-hyperactivity disorder: Report from a referral center

Objective:

The aim of the current study was to determine various aspects of methylphenidate adverse reactions in children with attention deficit-hyperactivity disorder (ADHD) in Iran.

Methods:

During the 6 months period, all children under methylphenidate treatment alone or along with other agents attending a university-affiliated psychology clinic were screened regarding all subjective and objective adverse drug reactions (ADRs) of methylphenidate. Causality and seriousness of detected ADRs were assessed by relevant World Health Organization definitions. The Schumock and Thornton questionnaire was used to determine preventability of ADRs.

Findings:

Seventy-one patients including 25 girls and 46 boys with ADHD under methylphenidate treatment were enrolled within the study period. All (100%) ADHD children under methylphenidate treatment developed at least one ADR. Anorexia (74.3%), irritability (57.1%), and insomnia (47.2%) were the most frequent methylphenidate-related adverse reactions. Except for one, all other detected ADRs were determined to be mild. In addition, no ADR was considered to be preventable and serious.

Conclusion:

Our data suggested that although methylphenidate related adverse reactions were common in children with ADHD, but they were mainly mild and nonserious.

Response to methylphenidate by adult and pediatric patients with attention-deficit/hyperactivity disorder: the Spanish multicenter DIHANA study

BACKGROUND

The purpose of this multicenter Spanish study was to evaluate the response to immediate-release methylphenidate by children and adults diagnosed with attention-deficit/hyperactivity disorder (ADHD), as well as to obtain information on current therapy patterns and safety characteristics.

METHODS

This multicenter, observational, retrospective, noninterventional study included 730 patients aged 4-65 years with a diagnosis of ADHD. Information was obtained based on a review of medical records for the years 2002-2006 in sequential order.

RESULTS

The ADHD predominantly inattentive subtype affected 29.7% of patients, ADHD predominantly hyperactive-impulsive was found in 5.2%, and the combined subtype in 65.1%. Overall, a significant lower Clinical Global Impression (CGI) score and mean number of DSM-IV TR (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision) symptoms by subtype were found after one year of treatment with immediate-release methylphenidate; CGI decreased from 4.51 to 1.69, symptoms of inattention from 7.90 to 4.34, symptoms of hyperactivity from 6.73 to 3.39, and combined subtype symptoms from 14.62 to 7.7. Satisfaction with immediate-release methylphenidate after one year was evaluated as "very satisfied" or "satisfied" by 86.90% of the sample; 25.75% of all patients reported at least one adverse effect. At the end of the study, 41.47% of all the patients treated with immediate-release methylphenidate were still receiving it, with a mean time of 3.80 years on therapy.

CONCLUSION

Good efficacy and safety results were found for immediate-release methylphenidate in patients with ADHD.

Safety of stimulant treatment in attention deficit hyperactivity disorder: part II

IMPORTANCE OF THE FIELD

Attention deficit hyperactivity disorder (ADHD) is the most common childhood psychiatric disorder and in at least 50% of cases persists into adulthood. Treatment of ADHD with stimulants is one of the oldest and most effective pharmacological treatments in psychiatry. Yet, there continues to be controversy over the safety of stimulant medications in the treatment of ADHD.

AREAS COVERED IN THIS REVIEW

This paper is a continuation of an earlier paper that reviewed the safety profile of newer stimulant agents, especially in relation to special populations. This part II reviews, through essentially an organ-system approach, the various clinical concerns that have been raised over the safety of stimulant medications. This includes neuropsychiatric, cardiovascular effects on growth and development, and a number of other less common concerns.

WHAT THE READER WILL GAIN

A thorough review of safety concerns in stimulants that emphasizes clinical information, case reports, open series or controlled trials relating to stimulant use in the treatment of ADHD.

TAKE HOME MESSAGE

While many safety concerns have been raised in the use of stimulants, the vast majority of treatment complications are either quickly reversible or easily manageable with appropriate clinical care. The negative consequences of untreated ADHD clearly outweigh the risks of the stimulant medicines when used in an appropriate and careful manner.

Chiropractic care for paediatric and adolescent Attention-Deficit/Hyperactivity Disorder: A systematic review

BACKGROUND

Psychostimulants are first line of therapy for paediatric and adolescent AD/HD. The evidence suggests that up to 30% of those prescribed stimulant medications do not show clinically significant outcomes. In addition, many children and adolescents experience side-effects from these medications. As a result, parents are seeking alternate interventions for their children. Complementary and alternative medicine therapies for behavioural disorders such as AD/HD are increasing with as many as 68% of parents having sought help from alternative practitioners, including chiropractors.

OBJECTIVE

The review seeks to answer the question of whether chiropractic care can reduce symptoms of inattention, impulsivity and hyperactivity for paediatric and adolescent AD/HD.

METHODS

Electronic databases (Cochrane CENTRAL register of Controlled Trials, Cochrane Database of Systematic reviews, MEDLINE, PsycINFO, CINAHL, Scopus, ISI Web of Science, Index to Chiropractic Literature) were searched from inception until July 2009 for English language studies for chiropractic care and AD/HD. Inclusion and exclusion criteria were applied to select studies. All randomised controlled trials were evaluated using the Jadad score and a checklist developed from the CONSORT (Consolidated Standards of Reporting Trials) guidelines.

RESULTS

The search yielded 58 citations of which 22 were intervention studies. Of these, only three studies were identified for paediatric and adolescent AD/HD cohorts. The methodological quality was poor and none of the studies qualified using inclusion criteria.

CONCLUSIONS

To date there is insufficient evidence to evaluate the efficacy of chiropractic care for paediatric and adolescent AD/HD. The claim that chiropractic care improves paediatric and adolescent AD/HD, is only supported by low levels of scientific evidence. In the interest of paediatric and adolescent health, if chiropractic care for AD/HD is to continue, more rigorous scientific research needs to be undertaken to examine the efficacy and effectiveness of chiropractic treatment. Adequately-sized RCTs using clinically relevant outcomes and standardised measures to examine the effectiveness of chiropractic care verses no-treatment/placebo control or standard care (pharmacological and psychosocial care) are needed to determine whether chiropractic care is an effective alternative intervention for paediatric and adolescent AD/HD.

Safety of stimulant treatment in attention deficit hyperactivity disorder: Part I

BACKGROUND

The safety profile of newer stimulant products is of interest. Because most studies focus on school-age children, there is also an increased interest in the treatment of other populations. Concern continues for the risk of substance abuse in the use of stimulants.

OBJECTIVE

The purpose of this paper is to review published data on the safety and tolerability of the newer forms of stimulants, treatment in special populations, and the risks of substance abuse and dependence in the treatment of attention deficit hyperactivity disorder.

METHODS

Literature obtained through Medline and Pubmed from 1995 were reviewed as well as key articles referenced in the literature.

CONCLUSIONS

The use of the newer stimulant agents shows a safety profile of frequent, but usually mild side effects. They are generally safe in special populations. The risk of developing long-term substance abuse with attention deficit hyperactivity disorder, without co-morbidities, is small and may decrease with proper treatment. More research is needed.

Das ADHS-Summercamp – Entwicklung und Evaluation eines multimodalen Programms

Die Studie beschäftigt sich mit der Frage, ob und inwieweit ein multimodales, massiertes, stringent lernpsychologisch orientiertes Gruppenprogramm (ADHS-Summercamp, ASCT; 12 Tage; 100 Stunden) die klinische ADHS-Kernsymptomatik günstig beeinflussen kann. Dabei sollte der besondere Einfluss von Response-Cost-Token (RCT) untersucht werden. Das ASCT wurde in einem Prä-Post1-Post2-Design mit einer standardisierten Elternberatungsgruppe (SEB) verglichen. An der Studie nahmen insgesamt 27 Kinder im Alter zwischen 6 und 17 Jahren teil, die nach Alter, Geschlecht und Kernsymptomatik per Zufall entweder der ASCT-Gruppe (N = 18) oder der SEB-Gruppe (N = 19) zugeordnet wurden. Während des Summercamps wurden neben einem sozialen Kompetenztraining schulbezogene Tests und Sport durchgeführt, wobei über alle Alltagssituationen hinweg das RCT systematisch angewendet wurde. Zudem erhielten die Kinder doppelblind, randomisiert und cross-over die drei folgenden Medikationen: Methylphenidat unretardiert, Methylphenidat retardiert und Placebo jeweils vier Tage lang. Das Verhalten der Kinder der ASCT-Gruppe wurde während des Summercamps zu festgelegten Zeitpunkten und in standardisierten Situationen durch geschulte Beobachter mithilfe von validierten Beobachtungsbögen (SKAMP; FBB-HKS) bewertet. Beide Gruppen erhielten zudem vor der Intervention, sechs Monate und zwei Jahre danach Eltern- und Lehrerbeobachtungsbögen, die sich u. a. auf die ADHS-Kernsymptomatik bezogen. Die varianzanalytische Auswertung zeigte eine signifikante Verbesserung der ADHS-Kernsymptomatik der ASCT-Gruppe, die auch nach zwei Jahren relativ stabil blieb. Dabei konnten diese Verbesserungen vorwiegend die Lehrer beobachten. Dagegen zeigte sich bei der SEB-Gruppe in der Lehrerbeobachtung eine Zunahme der Symptomatik nach der Beratung. Die Effekte der ASCT-Gruppe konnten vorwiegend auf die Wirkung des RCT zurückgeführt werden. Das Gruppentraining führt zu positiven, langfristigen klinischen Effekten, wenn es mit einem RCT verknüpft ist. Die Einführung von ADHS-Summercamps in Tageskliniken für Kinder und Jugendliche, aber auch in verhaltenstherapeutischen Ambulanzen und Praxen, bietet sich besonders aus ökonomischen Gründen an.

Psychopharmacology of ADHD in pediatrics: current advances and issues

Attention deficit hyperactivity disorder (ADHD) is a neurobehavioral developmental disorder found in 3% to 8% of children and adolescents. An important part of ADHD management is psychopharmacology, which includes stimulants, norepinephrine reuptake inhibitors, alpha-2 agonists, and antidepressants. Medications with the best evidence-based support for ADHD management are the stimulants methylphenidate and amphetamine. A number of newer, long-acting stimulants are now available and a number of new medications are considered that are under current research.