Drug therapy of attention deficit hyperactivity disorder: current trends

Meta-analysis of the effects of physical activity on executive function in children and adolescents with attention deficit hyperactivity disorder

BACKGROUND

Executive function is a core deficit in children with attention deficit hyperactivity disorder (ADHD). This study systematically reviewed the evidence for the effects of physical activity (PA) interventions on executive function in children and adolescents with ADHD and explored the moderating effects of key variables of PA on executive function.

METHODS

Relevant literature in four electronic databases, Pubmed, Web of Science, Cochrane Library, and Embase, were systematically searched. Revman 5.4 was used for data analysis, and combined effect sizes, heterogeneity tests, subgroup analyses, and sensitivity analyses were calculated. Egger's test in Stata 15.0 was used for publication bias testing.

RESULTS

A total of 24 articles with 914 participants were included. Meta-analysis showed that PA interventions improved inhibitory control (SMD = -0.50, 95%CI [-0.71, -0.29], P < 0.00001), working memory (SMD = -0.50, 95%CI [-0.83, -0.16], P = 0.004) and cognitive flexibility in children and adolescents with ADHD (SMD = -0.45, 95%CI [-0.81, -0.09], P = 0.01). Subgroup analysis revealed a moderating effect of intervention intensity, motor skill type, sessions of PA, and weekly exercise volume on executive function.

CONCLUSION

PA interventions had positive effects on improvements in core executive functions in children and adolescents with ADHD and were influenced by intervention intensity, type of motor skill, sessions of PA, and amount of exercise. This has practical implications for the formulation of PA interventions programs.

Xanthan-Gum/Pluronic-F-127-Based-Drug-Loaded Polymeric Hydrogels Synthesized by Free Radical Polymerization Technique for Management of Attention-Deficit/Hyperactivity Disorder

Smart and intelligent xanthan gum/pluronic F-127 hydrogels were fabricated for the controlled delivery of atomoxetine HCl. Different parameters such as DSC, TGA, FTIR, XRD, SEM, drug loading, porosity, swelling index, drug release, and kinetics modeling were appraised for the prepared matrices of hydrogels. FTIR confirmed the successful synthesis of the hydrogel, while TGA and DSC analysis indicated that the thermal stability of the reagents was improved after the polymerization technique. SEM revealed the hard surface of the hydrogel, while XRD indicated a reduction in crystallinity of the reagents. High gel fraction was achieved with high incorporated contents of the polymers and the monomer. An increase in porosity, drug loading, swelling, and drug release was observed with the increase in the concentrations of xanthan gum and acrylic acid, whereas Pluronic F-127 showed the opposite effect. A negligible swelling index was shown at pH 1.2 and 4.6 while greater swelling was observed at pH 7.4, indicating a pH-responsive nature of the designed hydrogels. Furthermore, a higher drug release was found at pH 7.4 compared to pH 1.2 and 4.6, respectively. The first kinetics order was followed by the prepared hydrogel formulations. Thus, it is signified from the discussion that smart xanthan gum/pluronic F-127 hydrogels have the potential to control the release of the atomoxetine HCl in the colon for an extended period of time.

Effects of different physical activity interventions on children with attention-deficit/hyperactivity disorder: A network meta-analysis of randomized controlled trials

Background

Previous studies have shown that physical activity interventions positively affect core symptoms and executive functioning in children with attention-deficit/hyperactivity disorder (ADHD). However, comparisons between different physical activity interventions still need to be made. This study is the first to analyze the effects of 10 different types of physical activity on children with ADHD through a network meta-analysis.

Methods

PubMed, Embase, Web of Science, and Cochrane Library databases were searched for randomized controlled trials on the effects of physical activity interventions on children with ADHD. The search time frame was from database creation to October 2022. Two investigators independently performed literature screening, extraction, and quality assessment. Network meta-analysis was performed with Stata 15.1.

Results

A total of 31 studies were included, and the results indicated that perceptual-motor training was the most effective in terms of motor ability and working memory (SUCRA = 82.7 and 73.3%, respectively). For attention problems and cognitive flexibility, aquatic exercise was the most effective (SUCRA = 80.9 and 86.6%, respectively). For social problems, horsemanship was the most effective (SUCRA = 79.4%). For inhibition switching, cognitive-motor training was the most effective (SUCRA = 83.5%).

Conclusion

Our study revealed that aquatic exercise and perceptual-motor training had a superior overall performance. However, the effects of various physical activity interventions on different indicators in children with ADHD can vary depending on the individual and the intervention's validity. To ensure an appropriate physical activity intervention is selected, it is important to assess the severity of symptoms exhibited by children with ADHD beforehand.

Discontinuation of methylphenidate after long-term exposure in nonhuman primates

Attention-deficit hyperactivity disorder (ADHD) is a common human neurobehavioral disorder that usually begins in early childhood. Methylphenidate (MPH) has been used extensively as a first-line medicine for the treatment of ADHD. Since ADHD is often diagnosed in early childhood and can persist for the entire lifespan, individuals may take MPH for many years. Given that in the course of one's lifetime a person may stop taking MPH for periods of time, or may implement lifestyle changes that may reduce the need for MPH entirely, it is important to understand how cessation of MPH affects the adult brain following long-term use of MPH. The blockage of the dopamine transporter (DAT) and the norepinephrine transporter (NET) by MPH may help with ADHD symptoms by boosting monoamine levels in the synapse. In the present study, microPET/CT was used to investigate possible neurochemical alterations in the cerebral dopamine system after cessation of long-term MPH administration in nonhuman primates. MicroPET/CT images were collected from adult male rhesus monkeys 6 months after they stopped receiving vehicle or MPH following 12 years of chronic treatment. The neurochemical status of brain dopaminergic systems was evaluated using the vesicular monoamine transporter 2 (VMAT2) ligand [¹⁸F]-AV-133 and a tracer for imaging dopamine subtype 2 (D₂) and serotonin subfamily 2 (5HT₂) receptors, [¹⁸F]-FESP. Each tracer was injected intravenously and ten minutes later microPET/CT images were obtained over 120 min. The binding potential (BP) of each tracer in the striatum was obtained using the Logan reference tissue model with the cerebellar cortex time activity curve (TAC) as an input function. Brain metabolism was also evaluated using microPET/CT images of [¹⁸F]-FDG. [¹⁸F]-FDG was injected intravenously, and ten minutes later, microPET/CT images were obtained over 120 min. Radiolabeled tracer accumulation in regions of interest (ROIs) in the prefrontal cortex, temporal cortex, striatum, and cerebellum were converted into standard uptake values (SUVs). Compared to the vehicle control group, the BPs of [¹⁸F] AV-133 and [¹⁸F]-FESP in the striatum were not significantly altered in MPH treated groups. Additionally, no significant differences were detected in the SUVs of [¹⁸F]-FDG in the MPH treated group compared with control. This study demonstrates that 6 months after cessation of long-term, chronic MPH treatment, there are no significant neurochemical or neural metabolic changes in the central nervous system (CNS) of non-human primates (NHPs) and suggests that microPET imaging is helpful in assessing the status of biomarkers of neurochemical processes linked to chronic CNS drug exposure. (Supported by NCTR).

Consequences of Acute or Chronic Methylphenidate Exposure Using Ex Vivo Neurochemistry and In Vivo Electrophysiology in the Prefrontal Cortex and Striatum of Rats

Methylphenidate (MPH) is among the main drugs prescribed to treat patients with attention-deficit and hyperactivity disease (ADHD). MPH blocks both the norepinephrine and dopamine reuptake transporters (NET and DAT, respectively). Our study was aimed at further understanding the mechanisms by which MPH could modulate neurotransmitter efflux, using ex vivo radiolabelled neurotransmitter assays isolated from rats. Here, we observed significant dopamine and norepinephrine efflux from the prefrontal cortex (PFC) after MPH (100 µM) exposure. Efflux was mediated by both dopamine and norepinephrine terminals. In the striatum, MPH (100 µM) triggered dopamine efflux through both sodium- and vesicular-dependent mechanisms. Chronic MPH exposure (4 mg/kg/day/animal, voluntary oral intake) for 15 days, followed by a 28-day washout period, increased the firing rate of PFC pyramidal neurons, assessed by in vivo extracellular single-cell electrophysiological recordings, without altering the responses to locally applied NMDA, via micro-iontophoresis. Furthermore, chronic MPH treatment resulted in decreased efficiency of extracellular dopamine to modulate NMDA-induced firing activities of medium spiny neurons in the striatum, together with lower MPH-induced (100 µM) dopamine outflow, suggesting desensitization to both dopamine and MPH in striatal regions. These results indicate that MPH can modulate neurotransmitter efflux in brain regions enriched with dopamine and/or norepinephrine terminals. Further, long-lasting alterations of striatal and prefrontal neurotransmission were observed, even after extensive washout periods. Further studies will be needed to understand the clinical implications of these findings.

Stimulant and non-stimulant drug therapy for people with attention deficit hyperactivity disorder and epilepsy

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) can co-occur in up to 40% of people with epilepsy. There is debate about the efficacy and tolerability of stimulant and non-stimulant drugs used to treat people with ADHD and co-occurring epilepsy.

OBJECTIVES

To assess the effect of stimulant and non-stimulant drugs on children and adults with ADHD and co-occurring epilepsy in terms of seizure frequency and drug withdrawal rates (primary objectives), as well as seizure severity, ADHD symptoms, cognitive state, general behaviour, quality of life, and adverse effects profile (secondary objectives).

SEARCH METHODS

We searched the following databases on 12 October 2020: Cochrane Register of Studies (CRS Web), MEDLINE (Ovid, 1946 to 9 October 2020), CINAHL Plus (EBSCOhost, 1937 onwards). There were no language restrictions. CRS Web includes randomised or quasi-randomised controlled trials from PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Cochrane Central Register of Controlled Trials (CENTRAL), and the Specialised Registers of Cochrane Review Groups including Epilepsy.  SELECTION CRITERIA: We included randomised controlled trials of stimulant and non-stimulant drugs for people of any age, gender or ethnicity with ADHD and co-occurring epilepsy.

DATA COLLECTION AND ANALYSIS

We selected articles and extracted data according to predefined criteria. We conducted primary analysis on an intention-to-treat basis. We presented outcomes as risk ratios (RRs) with 95% confidence intervals (CIs), except for individual adverse effects where we quoted 99% CIs. We conducted best- and worst-case sensitivity analyses to deal with missing data. We carried out a risk of bias assessment for each included study using the Cochrane risk of bias tool and assessed the overall certainty of evidence using the GRADE approach.

MAIN RESULTS

We identified two studies that matched our inclusion criteria: a USA study compared different doses of the stimulant drug osmotic-release oral system methylphenidate (OROS-MPH) with a placebo in 33 children (mean age 10.5 ± 3.0 years), and an Iranian study compared the non-stimulant drug omega-3 taken in conjunction with risperidone and usual anti-seizure medication (ASM) with risperidone and ASM only in 61 children (mean age 9.24 ± 0.15 years). All children were diagnosed with epilepsy and ADHD according to International League Against Epilepsy and Diagnostic and Statistical Manual of Mental Disorders, fourth edition, criteria, respectively. We assessed both studies to be at low risk of detection and reporting biases, but assessments varied from low to high risk of bias for all other domains. OROS-MPH No participant taking OROS-MPH experienced significant worsening of epilepsy, defined as: 1. a doubling of the highest 14-day or highest two-day seizure rate observed during the 12 months before the trial; 2. a generalised tonic-clonic seizure if none had been experienced in the previous two years; or 3. a clinically meaningful intensification in seizure duration or severity (33 participants, 1 study; low-certainty evidence). However, higher doses of OROS-MPH predicted an increased daily risk of a seizure (P < 0.001; 33 participants, 1 study; low-certainty evidence). OROS-MPH had a larger proportion of participants receiving 'much improved' or 'very much improved' scores for ADHD symptoms on the Clinical Global Impressions for ADHD-Improvement tool (33 participants, 1 study; low-certainty evidence). OROS-MPH also had a larger proportion of people withdrawing from treatment (RR 2.80; 95% CI 1.14 to 6.89; 33 participants, 1 study; moderate-certainty evidence). Omega-3 Omega-3 with risperidone and ASM were associated with a reduction in mean seizure frequency by 6.6 seizures per month (95% CI 4.24 to 8.96; 56 participants, 1 study; low-certainty evidence) and an increase in the proportion of people achieving 50% or greater reduction in monthly seizure frequency (RR 2.79, 95% CI 0.84 to 9.24; 56 participants, 1 study; low-certainty evidence) compared to people on risperidone and ASM alone. Omega-3 with risperidone and ASM also had a smaller proportion of people withdrawing from treatment (RR 0.65, 95% CI 0.12 to 3.59; 61 participants, 1 study; low-certainty evidence) but a larger proportion of people experiencing adverse drug events (RR 1.40, 95% CI 0.44 to 4.42; 56 participants, 1 study; low-certainty evidence) compared to people on risperidone and ASM alone.

AUTHORS' CONCLUSIONS

In children with a dual-diagnosis of epilepsy and ADHD, there is some evidence that use of the stimulant drug OROS-MPH is not associated with significant worsening of epilepsy, but higher doses of it may be associated with increased daily risk of seizures; the evidence is of low-certainty. OROS-MPH is also associated with improvement in ADHD symptoms. However, this treatment was also associated with a large proportion of treatment withdrawal compared to placebo. In relation to the non-stimulant drug omega-3, there is some evidence for reduction in seizure frequency in children who are also on risperidone and ASM, compared to children who are on risperidone and ASM alone. Evidence is inconclusive whether omega-3 increases or decreases the risk of adverse drug events. We identified only two studies - one each for OROS-MPH and omega-3 - with low to high risk of bias. We assessed the overall certainty of evidence for the outcomes of both OROS-MPH and omega-3 as low to moderate. More studies are needed. Future studies should include: 1. adult participants; 2. a wider variety of stimulant and non-stimulant drugs, such as amphetamines and atomoxetine, respectively; and 3. additional important outcomes, such as seizure-related hospitalisations and quality of life. Clusters of studies which assess the same drug - and those that build upon the evidence base presented in this review on OROS-MPH and omega-3 - are needed to allow for meta-analysis of outcomes.

Effects of physical exercise on attention deficit and other major symptoms in children with ADHD: A meta-analysis

PURPOSE

To explore the effects of physical exercise intervention on the cardinal symptoms, motor skills and executive function among children with attention deficit hyperactivity disorder (ADHD).

METHODS

Literature searches for randomized controlled trials (RCTs) were performed in PubMed, The Cochrane Library, Web of Science, Embase, CNKI, CBM, VIP and Wanfang databases from the time of database construction to March 28, 2021. Screening was conducted based on inclusion and exclusion criteria. The Cochrane bias risk assessment tools were used to evaluate methodological quality. Relevant data were analyzed with RevMan5.3.5 software, and Stata16.0 was used for publication bias tests.

RESULTS

A total of 15 RCTs with 734 subjects were included. The meta-analysis showed that physical exercise can improve the attention of ADHD children (standardized mean difference [SMD] = -0.60, 95% confidence interval [CI] [-1.10, -0.11], p < 0.01), executive function (SMD = 1.22, 95% CI [0.61, 1.82], p < 0.01), and motor skills (SMD = 0.67, 95% CI [0.22, 1.12], p < 0.01). There were no significant effects on hyperactivity (SMD = 0.06, 95% CI [-0.26, 0.37], p = 0.72), depression (SMD = -0.72, 95% CI [-1.55, 0.11], p = 0.09), social problems (SMD = -0.27, 95% CI [-0.64, 0.09], p = 0.14), or aggressive behavior (SMD=-0.24, 95% CI [-0.69, -0.21], p = 0.30). Intervention duration and frequency might be the source of heterogeneity.

CONCLUSION

Physical exercise can help alleviate the symptoms of ADHD in children. Specifically, it can improve attention, executive function, and motor skills.

OUP accepted manuscript

A simple, robust stability indicating RP-HPLC method was developed for simultaneous quantification of serdexmethyl phenidate and dexmethyl phenidate in a fixed capsule dosage form. This is the first method to be reported for simultaneous estimation and quantification of degradation products produced from forced stressing of the dosage form as per ICH guidelines. The chromatographic separation was attained on Waters X-terra C18 column using a mixture of trifluoro acetic acid and acetonitrile (70:30 v/v) as mobile phase with a flow rate of 1 mL, monitored at 265 nm over a run time of 10 min. Serdexmethyl phenidate and dexmethyl phenidate were eluted with retention times of 2.71 min and 7.33 min, respectively. The method displayed linear responses in the range of 4.2-63 μg/mL (0.9994) for serdexmethyl phenidate and 0.9 to 3.5 μg/mL (0.9998) for dexmethyl phenidate, respectively. The percentage recoveries of the two drugs were found within the acceptable limits. Forced degradation was conducted and showed considerable degradation in various stress conditions. It also confirms the specificity of the method as no interference peaks were observed concerning for to stress products. This method can be routinely used in quality control labs for simultaneous determination of respective drugs in marketed dosage form.

Effects of methylphenidate on height, weight and blood biochemistry parameters in prepubertal boys with attention deficit hyperactivity disorder: an open label prospective study

Background: Adverse effects of stimulants on growth in children have long been studied, but the results remain to be clarified, because metabolic changes or predictors accompanying the growth deviations were not sufficiently studied. Objective: This open label-prospective study investigated the effects of methylphenidate (MPH) on weight, height, blood biochemistry in children with attention deficit hyperactivity disorder (ADHD). Method: Prepubertal boys treated with MPH in Child and Adolescent Psychiatry Clinic at Antalya Training and Research Hospital in Health Sciences University, Turkey were recruited. Height and weight z-scores and fasting blood samples were taken at baseline and 6^th month. Changes were compared by paired-samples t-test or Wilcoxon signed-rank test. Any association between the changes in growth and biochemical values was analyzed by Spearman's Rank-Order Correlation. The statistical significance threshold was p<0.01. Results: 31 boys aged 74 to 104 months were enrolled in the study sample (mean=87.6, Standard Deviation (SD)=9.2). Osmotic release oral system-MPH (18 mg/day) was used in 77.4% (N=24) and immediate release-MPH (5 mg three times a day) in 22.5% (N=7). Average daily drug dose was 0.66 mg/kg (SD=0.12). Baseline weight z-score was 0.63 (SD=1.12), decreased significantly at 6 months (0.24 [SD=1.04]) (Z=-4.44, p=0.000, r=0.5) (median z-score was 0.53 at baseline, -0.11 at 6 months). Baseline height z-score (0.23[SD=0.87]) was not suppressed significantly at 6 months (0.28[SD=0.85])(t(30) = ‒1.50, p=0.14). Glucose (t(30) = -4.33, p=0.000, r=0.6), creatinine (t(30)=-3.28, p=0.003, r=0.5) and 25OH-VitD (N=29, Z=-3.98, p=0.000, r=0.5) increased but alkaline phosphatase (ALP) decreased (t(28)=3.63, p=0.001, r=0.5). The differences in W-SDS and ALP were positively correlated (r=0.47, p=0.009). Conclusions: Our results indicate the importance of monitoring blood variables that may accompany growth changes early in MPH treatment and should be further assessed in larger samples.

MicroPET/CT assessment of neurochemical effects in the brain after long-term methylphenidate treatment in nonhuman primates

Methylphenidate (MPH) is a psychostimulant approved by the FDA to treatment Attention-Deficit Hyperactivity Disorder (ADHD). MPH is believed to exert its pharmacological effects via preferential blockade of the dopamine transporter (DAT) and the norepinephrine transporter (NET), resulting in increased monoamine levels in the synapse. We used a quantitative non-invasive PET imaging technique to study the effects of long-term methylphenidate use on the central nervous system (CNS). We conducted microPET/CT scans on young adult male rhesus monkeys to monitor changes in the dopaminergic system. We used [¹⁸F] AV-133, a ligand for the vesicular monoamine transporter 2 (VMAT2), and [¹⁸F]FESP a ligand for the D₂ and 5HT₂ receptors. In this study we evaluated the effects if chronic MPH treatment in the nonhuman primates (NHP). Two-year-old, male rhesus monkeys were orally administered MPH diluted in the electrolyte replenisher, Prang, twice a day, five days per week (M-F) over an 8-year period. The dose of MPH was gradually escalated from 0.15 mg/kg initially to 2.5 mg/kg/dose for the low dose group, and 1.5 mg/kg to 12.5 mg/kg/dose for the high dose group (Rodriguez et al., 2010). Scans were performed on Mondays, about 60 h after their last treatment, to avoid the acute effects of MPH. Tracers were injected intravenously ten minutes before microPET/CT scanning. Sessions lasted about 120 min. The Logan reference tissue model was used to determine the Binding Potential (BP) of each tracer in the striatum with the cerebellar cortex time activity curve as an input function. Both MP treatment groups had a lower [¹⁸F] AV-133 BP, although this failed to reach statistical significance. MPH treatment did not have a significant effect on The BP of [¹⁸F] FESP in the striatum. Long-term administration of MPH did not significant change any of the marker of monoamine function used here. These data suggest that, despite lingering concerns, long-term use of methylphenidate does not negatively impact monoamine function. This study also demonstrates that microPET imaging can distinguish differences in binding potentials of a variety of radiotracers in the CNS of NHPs. This approach may provide minimally-invasive biomarkers of neurochemical processes associated with chronic exposure to CNS medications. (Supported by NCTR).

Prescription patterns and medication adherence in preadolescent children with attention deficit hyperactivity disorder

BACKGROUND

Nonadherence in attention deficit hyperactivity disorder (ADHD) can be as high as 80%, yet studies on adherence to medications in preadolescent children are few. Recent Indian trends in prescription patterns are lacking.

AIM

The present study assesses prescription patterns and adherence to medications in preadolescent children with ADHD.

MATERIALS AND METHODS

Fifty children aged 5-12 years with ADHD, who were on medications for at least 6 months, were enrolled. Their sociodemographic factors and prescription details were noted. Vanderbilt ADHD Diagnostic Parents Rating Scale and Compliance Rating Scale were administered.

RESULTS

Sixty-two percent of the children had good compliance, whereas 38% showed reluctance. Adherence was better in children with shorter duration of illness, lesser severity, absence of side effects, and stimulant prescription. Non-stimulant-based combination (40%) was more common compared to stimulants (28%), with atomoxetine and risperidone being the most commonly prescribed medications.

CONCLUSIONS

Adherence to medications in preadolescent children with ADHD is good. Associated factors and implications are discussed.

Parent and Teacher Training Increases Medication Adherence for Primary School Children With Attention-Deficit/Hyperactivity Disorder

Objective: Attention-deficit/hyperactivity disorder (ADHD) is a common neurobiological disorder for which effective and safe medication is recommended as first-line treatment. However, many parents and teachers do not believe that ADHD is a disorder or do not accept medication treatment in China. Treatment is often short term or intermittent. Our study aimed to investigate the clinical effect of employing a 4-week, session-based training for both parents and teachers in improving medication adherence for primary school children with ADHD. Methods: From January 2018 to December 2018, a total of 5,118 primary school children were screened. Among 211 children diagnosed with ADHD, 116 were assigned to the intervention group and 95 to the control group. This study provided systematic training for parents and teachers in the intervention group. The training consisted of education about the disorder and ADHD behavioral intervention for both parents and teachers as well as classroom management techniques for just the teachers. A cluster randomized controlled trial (RCT) was conducted to investigate the effect of this training at 6 months follow-up. The study determined medication adherence using a questionnaire and scoring with a rating scale at baseline and at the 6 month follow-up endpoint. The questionnaire was self-report. Results: The study population had a relatively low rate of attention deficit hyperactivity disorder (4.1%) compared to the generally accepted prevalence. After the training, more parents and teachers believed that ADHD is a neurobiological disorder and that medication is the first line treatment. At 6 months follow-up, the Medication Adherence Report Scale (MARS) score for the intervention group was 22.8 ± 0.75 and 16.5 ± 1.63 for the control group (t = 5.217, P < 0.01). Based on parents' reports and medical records, 82 children (70.69%) were continuously taking medication for 6 months in the intervention group, while only 35 children (36.84%) were doing so in the control group. In the intervention group, the mean SNAP-IV score was 1.98 ± 0.42 at baseline but 0.99 ± 0.31 at 6-month follow-up. In the control group, the mean SNAP-IV score was 1.89 ± 0.47 at baseline but 1.37 ± 0.42 at 6-months follow-up (F = 2.67, P = 0.009). Factors influencing medication adherence for children with ADHD were parent's beliefs, teacher's beliefs, socioeconomic status, adverse effect, insurance coverage, gender, and trust of the medical system. Conclusions: Our findings indicate that comprehensive training programs improve the understanding of ADHD and medication adherence for both children's parents and teachers, providing a promising approach for improving clinical efficacy for children with ADHD.

Sustained stimulation? Characteristics of modified release and immediate release stimulant exposures reported to the national poison data system

OBJECTIVE

We sought to examine ADHD modified release (MR) and immediate release (IR) stimulant ingestion exposures reported to the National Poison Data System (NPDS) to characterize the nature of the exposures and the outcomes associated with them.

METHODS

The NPDS was queried for all single-substance exposures to MR and IR ADHD preparations between January 1, 2007 and December 31, 2017. MR and IR preparations were identified by a generic code of "amphetamine and related compounds" or "methylphenidate" and specific product name containing XR, CD, ER, LA, and SR.

RESULTS

A total of 15,796 MR ingestions and 23,418 IR ingestions were identified and followed to known outcome. The majority of ingestions occurred in male patients and in own residence. More serious outcomes (moderate, major, or death) were more common in adult IR and MR ingestions as compared to pediatric; rates of serious outcome increased with age amongst pediatric ingestions. Unintentional ingestions were more common in both MR and IR pediatric cases while intentional ingestions occurred more frequently in adult cases. Symptoms consistent with a hyperadrenergic state were experienced in adult and pediatric patients for both MR and IR ingestions. Supportive care including benzodiazepine administration was more common in IR than MR ingestions. Decontamination with whole bowel irrigation was infrequent.

CONCLUSION

Rates of more serious outcome were similar between IR and MR ADHD stimulant ingestions. More serious outcomes were associated with advancing age and intentional ingestions. Similar rates of agitation, tachycardia, and hypertension were experienced by pediatric IR and MR ingestions while more common in adult IR as compared to MR ingestions. Rates of decontamination with whole bowel irrigation were overall low.

Does Diet Affect the Symptoms of ADHD?

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is the most common psychiatric diagnosis in childhood and adolescence, with an estimated worldwide-pooled prevalence of 5,29%. The type of treatment depends on several factors. Psychopharmacological treatment entails undesirable side effects, with unclear long-term benefits, which has led the scientific community to investigate other therapeutic approaches, such as dietary interventions.

METHOD

The authors conducted a classical review on the current treatment recommended in individuals with ADHD diagnosis, their dietary patterns, as well as dietary factors possibly implicated in the etiology and treatment of this disorder. An extensive bibliographic research was carried out in the databases PubMed, The Cochrane Library and the National Guideline Clearinghouse.

DISCUSSION

The most common dietary interventions in the case of ADHD are food supplementation diets (e.g. PUFAs, vitamins) and elimination diets. Supplementation with omega-3 PUFAs lacks further studies that can validate them as an effective therapeutic approach in this disorder. Also, regarding vitamin supplementation, studies are not consistent as to their role in the etiology of ADHD. Elimination diets are unclear as to the benefits provided in individuals with ADHD. Children with ADHD are less likely to engage in healthy lifestyle behaviors than non-ADHD youth.

CONCLUSION

There is no clear evidence that supports dietary interventions for the treatment of ADHD. The effects of unhealthy diet patterns in ADHD individuals are not yet fully understood and, like the general population, children with ADHD may benefit from a healthy lifestyle.

Potential Negative Effects of Dextromethorphan as an Add-On Therapy to Methylphenidate in Children With ADHD

Objectives: Methylphenidate (MPH) is highly effective in controlling the symptoms of attention-deficit/hyperactivity disorder (ADHD), but some children with ADHD either do not respond to, or do not tolerate, treatment. Dextromethorphan (DM) is a neuroprotective agent which has been used in the treatment of neuropsychiatric disorders. This clinical trial had examined the effect of DM on the use of MPH in the children with ADHD. Methods: This randomized double-blind clinical trial had evaluated 44 male outpatients, aged between 6 and 12 years, with a diagnosis of ADHD. The study subjects were randomly assigned into one of the two groups: receiving MPH alone (15-60 mg per day) or MPH plus DM (30-60 mg per day) for 8 weeks. Assessments, comprising the Chinese version of the Child Behavior Checklist (CBCL-C) scale and the Swanson, Nolan and Pelham Questionnaire (SNAP)-IV rating tests conducted by parents and the serum cytokines measured by microarray and enzyme-linked immunosorband assay (ELISA), were compared between groups at baseline and at 8 weeks after the medication was started. Results: There were a significant decrease at the mean scores of both CBCL-C and SNAP-IV scales after 8 weeks of treatment, but no significant differences between MPH and MPH+DM groups. Compared with the MPH-only group, the mean scores of some psychometric parameters reported on the CBCL-C and SNAP-IV scales regarding time effects as well as the attention problems on the CBCL-C scale regarding group effect were significantly higher in the DM+MPH group. Although there were no significant differences in the levels of various serum cytokines between groups, the subjects in the DM-MPH group had relatively fewer and lower levels of adverse effects. Significant interactions were found between the withdrawn/depression item reported on the CBCL-C scale and tumor necrosis factor α (ခTNF-α) (p = 0.027), as well as between thought problems item on the CBCL-C and TNF-α (p = 0.028) in subjects who had received DM+MPH treatment. Conclusion: Following the trial, DM+MPH was not superior to MPH alone for the treatment of children with ADHD, yet DM may potentially have negative effects on ADHD symptoms when combined with MPH. Clinical Trial Registration: Clinicaltrials.gov, trial number: NCT01787136.

Chronic Methylphenidate Alters Tonic and Phasic Glutamate Signaling in the Frontal Cortex of a Freely-Moving Rat Model of ADHD

Glutamate dysfunction has been implicated in a number of substance of abuse studies, including cocaine and methamphetamine. Moreover, in attention-deficit/hyperactivity disorder (ADHD), it has been discovered that when the initiation of stimulant treatment occurs during adolescence, there is an increased risk of developing a substance use disorder later in life. The spontaneously hypertensive rat (SHR) serves as a phenotype for ADHD and studies have found increased cocaine self-administration in adult SHRs when treated with the stimulant methylphenidate (MPH) during adolescence. For this reason, we wanted to examine glutamate signaling in the pre-limbic frontal cortex, a region implicated in ADHD and drug addiction, in the SHR and its progenitor control strain, the Wistar Kyoto (WKY). We chronically implanted glutamate-selective microelectrode arrays (MEAs) into 8-week-old animals and treated with MPH (2 mg/kg, s.c.) for 11 days while measuring tonic and phasic extracellular glutamate concentrations. We observed that intermediate treatment with a clinically relevant dose of MPH increased tonic glutamate levels in the SHR but not the WKY compared to vehicle controls. After chronic treatment, both the SHR and WKY exhibited increased tonic glutamate levels; however, only the SHR was found to have decreased amplitudes of phasic glutamate signaling following chronic MPH administration. The findings from this study suggest that the MPH effects on extracellular glutamate levels in the SHR may potentiate the response for drug abuse later in life. Additionally, these data illuminate a pathway for investigating novel therapies for the treatment of ADHD and suggest that possibly targeting the group II metabotropic glutamate receptors may be a useful therapeutic avenue for adolescents diagnosed with ADHD.

The effect of adding ferrous sulfate to methylphenidate on attention-deficit/hyperactivity disorder in children

Attention deficit/hyperactivity disorder (ADHD) is one of the most common psychiatric disorders in children with several complications. This study was conducted to investigate the effect of adding ferrous sulfate to methylphenidate in decreasing ADHD symptoms. This study was a double-blind, randomized clinical trial. In this study, 42 nonanemic children with ADHD and serum ferritin below 30 mg/ml were enrolled according to convenience sampling and randomly assigned to two groups of 21 each, cases and controls. The two groups were matched for age and sex. The case group was administered with ferrous sulfate 5 mg/kg in addition to methylphenidate up to 1 mg/kg and the control group with methylphenidate alone. The scores on child symptoms inventory-4 (CSI-4) were recorded at baseline and after 2 months of treatment. Data were analyzed by t-test, Pearson's correlation coefficient, and repeated measures ANOVA in SPSS 16. The scores on CSI-4 decreased significantly at month 2 in both groups (P < 0.001). The scores on attention deficit and hyperactivity subscales of the CSI-4 were significantly lower in the case group than the control group (P < 0.05). The total score on CSI-4 decreased more markedly in the case group (P < 0.04). Use of ferrous sulfate plus methylphenidate can be effective in reducing ADHD symptoms in nonanemic children with low serum ferritin.

Enhanced Physical Activity Improves Selected Outcomes in Children With ADHD: Systematic Review

This review examines associations between physical activity (PA) and cognitive, behavioral, and physiological outcomes in children with attention-deficit/hyperactivity disorder (ADHD). We reviewed studies on participants ≤18 years old, published in English between January 1998 and December 2014, in PubMed, CINAHL, PsycINFO, and Cochrane Reviews. Twenty-six studies were grouped into two categories: those that did and did not account for effects of ADHD medications. The first category showed lower levels of PA and improved cognitive and behavioral outcomes in youth whose ADHD was treated with medications. The second category showed a positive association between PA levels and cognitive and behavioral outcomes in youth whose ADHD was not treated with medications. For both categories of studies, results were inconclusive regarding physiological outcomes. Randomized controlled trials are needed to better clarify the relationship between PA and outcomes in youth with ADHD, and particularly to understand the impact of ADHD medications on that relationship.

Should clinical trial research of psychotropic medication in autism control for gastrointestinal symptoms?

Recent research has established that many children and adult diagnosed with autism experience gastrointestinal symptoms. Furthermore, research has demonstrated that gastrointestinal symptoms can impact drug availability and absorption. In this paper we explore the presence of gastrointestinal symptoms in autism and put forth a call for a formal evaluation of the potential relationship between gastrointestinal symptoms and psychotropic medication effectiveness in individuals with autism.

Influence of methylphenidate treatment assumptions on cognitive function in healthy young adults in a double-blind, placebo-controlled trial

Background

Increasing numbers of students use stimulants such as methylphenidate (MPH) to improve their study capacity, making them prone to subsequent prolonged drug abuse. This study explored the cognitive effects of MPH in students who either assumed they received MPH or assumed they received a placebo.

Methods

In a double-blind, randomized, placebo-controlled trial with a between-subjects design, 21 students were subjected to partial sleep deprivation, receiving no more than 4 hours sleep the night before they were tested. In the morning, they were given either a placebo or 20 mg of MPH. They then performed free recall verbal tests and Go/No-Go tasks repeatedly, their moods were evaluated using Profile of Mood States and their tiredness was assessed using a visual analog scale, with evaluation of vigilance.

Results

No significant differences were found between those subjects who received MPH and those who received a placebo. However, significant differences were found between subjects who assumed they had received MPH or had no opinion, and those who assumed they had received a placebo. At three minutes, one hour, and one day after memorizing ten lists of 20 words, those who assumed they had received MPH recalled 54%, 58%, and 54% of the words, respectively, whereas those who assumed they had received placebo only recalled 35%, 37%, and 34%.

Conclusion

Healthy, partially sleep-deprived young students who assume they have received 20 mg of MPH experience a substantial placebo effect that improves consolidation of information into long-term memory. This is independent of any pharmacologic effects of MPH, which had no significant effects on verbal memory in this study. This information may be used to dissuade students from taking stimulants such as MPH during examination periods, thus avoiding subsequent abuse and addiction.