The Impact of Stimulant Medications on Blood Pressure and Body Mass Index in Children with Attention Deficit Hyperactivity Disorder

OBJECTIVE

To describe changes in blood pressure (BP) and body mass index (BMI) associated with stimulant medication fills in children.

METHODS

Observational, retrospective matched cohort study of children 6-17.9 years initiating stimulant medication between 7/1/2010-6/30/2017 matched 1:3 by age, race, ethnicity, and sex to children with no stimulant use during this period. All BPs and BMIs recorded during ambulatory visits were identified. Generalized linear models were used to estimate differences in change in systolic BP (SBP), diastolic BP (DBP), and BMI over time.

RESULTS

The 686 children with stimulant prescription fills and 2048 matched controls did not differ by baseline SBP or BMI. The matched control group (30.5% female, mean age 11.2 ± 3.4 years 79.7% white) was more likely to be publicly insured (35% vs. 21%, P < .01). After adjusting for baseline values, over a mean follow-up of 144 days change in SBP or DBP did not differ significantly between patients with stimulant medication fills and matched controls. Stimulant use was associated with a 4.7 percentile decrease in BMI percentile compared to matched controls (95% CI: 3.69, 5.71; P < .01).

CONCLUSIONS

In a pediatric primary care cohort, stimulant prescription fills were associated with marked decreases in BMI but no significant changes in BP over time.

Understanding ADHD in AAPI College Students: Prevalence, Comorbidities, Impairments, and Treatment Utilization

OBJECTIVE

Asian American and Pacific Islander (AAPI) students with ADHD may face increased risk for college maladjustment due to cultural factors and a tendency to delay treatment. This is the first study to examine ADHD prevalence, ADHD-related impairments and comorbidities, and ADHD treatment utilization in AAPI college students.

METHOD

AAPI, White, Hispanic, and Black undergraduates (n = 258,005) from the American College Health Association-National College Health Assessment II survey were included in the study.

RESULTS

AAPI students had lower ADHD prevalence rates than White and Black students, and similar prevalence to Hispanic students. AAPI students with ADHD had significantly higher risk for comorbidities and social and academic impairments, compared to White students with ADHD. Approximately half of AAPI students with ADHD did not utilize treatment despite experiencing psychiatric comorbidities and functional impairments.

CONCLUSION

AAPI college students with ADHD are underutilizing treatment despite elevated psychiatric comorbidities and functional impairment.

The longitudinal influence of ADHD status and stimulant medication on body mass index and blood pressure among youth with obesity

BACKGROUND

Youth with attention-deficit hyperactivity disorder (ADHD) are more vulnerable to developing obesity. Stimulant medication use, an evidence-based treatment for ADHD, is associated with lower body mass index (BMI) and higher blood pressure among non-overweight youth.

OBJECTIVES

The purpose of this study was to examine the longitudinal influence of ADHD and stimulant medication use on BMI and blood pressure among a sample of 456 youth with overweight and obesity treated in a paediatric weight management clinic.

METHODS

Mixed linear modelling examined the main and interactive effects of time by ADHD status and stimulant medication use on BMI and blood pressure.

RESULTS

Youth without ADHD experienced a significantly faster decrease in BMI compared to youth with ADHD (p < 0.001). Youth with ADHD who were taking stimulant medication had a significantly faster decrease in BMI compared to youth with ADHD who were not taking stimulant medication (p = 0.009). There was no significant effect of ADHD status or stimulant medication use on diastolic or systolic blood pressure trajectories over time (ps >0.05).

CONCLUSIONS

Results from this study suggest that youth with ADHD who are not taking stimulant medication may not benefit from clinical weight management to the same extent as either youth without ADHD or youth with ADHD who are taking a stimulant medication.

Evaluating serdexmethylphenidate and dexmethylphenidate capsules as a once-daily treatment option for ADHD

INTRODUCTION

Attention deficit/hyperactivity disorder (ADHD) is a common behavioral disorder which is best treated through a combination of medication and behavioral therapy, with stimulant medications serving as a first-line treatment approach. Serdexmethylphenidate (SDX), a prodrug of dexmethylphenidate (d-MPH), a commonly utilized stimulant medication, has recently received approval and is marketed in the U.S.A.

AREAS COVERED

This review summarizes peer-reviewed literature on SDX published between 2021-2023 and a review of data available from ClinicalTrials.gov.

EXPERT OPINION

SDX represents a new option for treatment for ADHD. It is unique in its prodrug design and achieves a relatively extended duration of action in comparison to other stimulant formulations. Although the research is relatively limited thus far, early data suggests it to be a safe medication to consider with side effects being similar to other stimulant medications. Its prodrug design is useful in potentially serving as a deterrent to intentional parenteral abuse and its ability to be opened and sprinkled makes it an option for those individuals with ADHD who might be unable to swallow pills.

Predictors of Stimulant Medication Continuity in Children with Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

The objective of this study was to examine the simultaneous impact of patient-related and parent-related factors, medication-related factors, and health care system-related factors on attention-deficit/hyperactivity disorder (ADHD) medication continuity.

METHOD

Stimulant-naïve children (N = 144, M age = 8 yrs, 71% male) with ADHD completed a methylphenidate (MPH) trial and were followed for 1 year after trial completion and return to community care. Multivariable analysis investigated predictors of (1) having at least 1 filled ADHD prescription after return to community care versus none and (2) having more days covered with medicine after return to community care. Predictors included race; age; sex; income; baseline ADHD symptom severity; MPH trial experience; child and parent mental health conditions; and parent beliefs about ADHD, ADHD medications, and therapeutic alliance.

RESULTS

One hundred twenty-one children (84%) had at least 1 filled ADHD medication prescription (mean = 178 d covered by medication) in the year after return to community care. Multivariable models found that a weaker perceived clinician-family working alliance predicted not filling any ADHD prescriptions. Among those who filled ≥1 prescription, factors linked to fewer days of ADHD medication coverage included child sociodemographic factors (non-White race, older age, being female, and lower income), lower parent beliefs that the child's ADHD affects their lives, and higher parent beliefs that medication is harmful, while child oppositional defiant disorder and parental ADHD predicted having more days of medication coverage.

CONCLUSION

Child demographic factors, parent beliefs, and medication-related factors are associated with continuation of ADHD medication. These findings may facilitate the development of effective strategies to improve ADHD medication continuity for children from diverse groups.

Stimulant Therapy Utilization for Neurocognitive Deficits in Mild Traumatic Brain Injury

CONTEXT

There are 3.8 million mild traumatic brain injuries (mTBIs) that occur each year in the United States. Many are left with prolonged life-altering neurocognitive deficits, including difficulties in attention, concentration, mental fatigue, and distractibility. With extensive data on the safety and efficacy of stimulant medications in treating attention deficit, concentration difficulties and distractibility seen with attention deficit disorder, it is not surprising that interest continues regarding the application of stimulant medications for the persistent neurocognitive deficits in some mTBIs.

EVIDENCE ACQUISITION

Studies were extracted from PubMed based on the topics of neurocognitive impairment, mTBI, stimulant use in mTBI, stimulants, and the association between attention deficit/hyperactivity disorder and mTBI. The search criteria included a date range of 1999 to 2020 in the English language.

STUDY DESIGN

Literature review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Currently, there is very limited literature, and no guidelines for evaluating the use of stimulant medication for the treatment of prolonged neurocognitive impairments due to mTBI. However, a limited number of studies have demonstrated efficacy and safety of stimulants in the treatment of neurocognitive sequelae of mTBI in the adult, pediatric, military, and athletic populations.

CONCLUSION

There is limited evidence to suggest stimulant medication may be beneficial in patients with mTBI with persistent neurocognitive symtpoms. The decision to utilize stimulant medication for mTBI patients remains physician and patient preference dependent. Given the limited encouraging data currently available, physicians may consider stimulant medication in appropriate patients to facilitate the recovery of prolonged neurocognitive deficits, while remaining cognizant of potential adverse effects.

Open-Label Dose Optimization of Methylphenidate Extended-Release Orally Disintegrating Tablet in a Laboratory Classroom Study of Children with Attention-Deficit/Hyperactivity Disorder

Objective: To examine the efficacy, safety, and tolerability of methylphenidate extended-release orally disintegrating tablets (MPH XR-ODT) for the treatment of attention-deficit/hyperactivity disorder (ADHD) during the open-label dose-optimization/stabilization period of a phase 3 laboratory classroom study. Methods: Children (6-12 years) diagnosed with ADHD were enrolled. Treatment was initiated with MPH XR-ODT 20 mg daily. Doses were adjusted weekly by 10-20 mg during the 4-week dose-optimization period (visits 2-5) until an optimal dose was reached. The optimal dose was sustained during a 1-week stabilization period (visits 6-7). Efficacy was assessed using the ADHD Rating Scale-IV (ADHD-RS-IV) score and the Clinical Global Impression-Improvement (CGI-I) score. Adverse events (AEs) were recorded throughout the study. A secondary subgroup analysis by baseline ADHD-RS-IV score, sex, age, and weight was also performed. Results: The mean (standard deviation [SD]) final optimized MPH XR-ODT daily dose was 41.8 (14.6) mg and ranged from 20 to 60 mg. Final optimized dose was higher for children with more severe baseline ADHD-RS-IV total scores. ADHD-RS-IV total scores decreased progressively during dose optimization, with a mean (SD) change from baseline at visit 7 of -21.4 (8.9). CGI-I scores shifted from "minimally improved" (mean [SD]: 3.1 [1.1]) at visit 3 to "much improved" (1.6 [0.6]) at visit 7. Baseline ADHD-RS-IV total score was highest for participants optimized to 40 mg (mean [standard error]: 40.0 [1.4]) and lowest for those optimized to 20 mg (34.8 [2.1]). By visit 6, mean ADHD-RS-IV score was comparable for all optimized dose groups. Common treatment-emergent AEs (≥5% of participants) included decreased appetite, upper abdominal pain, headaches, and insomnia. Conclusions: Dose optimization of MPH XR-ODT led to a reduction in ADHD symptoms, indicated by a decrease in ADHD-RS-IV and CGI-I scores. AEs were consistent with those of other MPH products. Clinical Trial Registry: NCT01835548 (ClinicalTrials.gov).

Does attention-deficit hyperactivity disorder medication reduce entrepreneurship?

Attention-deficit hyperactivity disorder (ADHD) is a highly inheritable condition with a rather stable prevalence over time and geography, and it is associated with a broad range of negative life outcomes. Increasing knowledge on the condition has led to a growing trend of dampening ADHD symptoms through medication. Although this development has led to many positive outcomes, the broader societal implications are still poorly understood. In particular, person-level studies suggest that ADHD-like behavior may possess some advantages for engaging in entrepreneurship and the initiation of new businesses, which is considered a key activity for economic development. Using recent panel data from 11 countries and one special administrative region (SAR), we investigate if the increasing use of ADHD medication in adults is associated with an unintended outcome of reducing entrepreneurship. We find that a roughly one unit increase in the prevalence of adult ADHD medication is associated with a one unit decrease in limited liability company registrations per working age population. In practical terms, the effect of a one within-country/SAR standard deviation increase of adult ADHD medication prevalence corresponds to a decrease in new business formation of 20% of its mean in the sample.

An innovative SMS intervention to improve adherence to stimulants in children with ADHD: Preliminary findings

BACKGROUND

Although large datasets document that stimulants decrease the risk for many adverse ADHD-associated outcomes, compliance with stimulants remains poor.

AIMS

This study examined the effectiveness of a novel ADHD-centric text messaging-based intervention aimed to improve adherence to stimulant medications in children with ADHD.

METHODS

Subjects were 87 children aged 6-12, who were prescribed a stimulant medication for ADHD treatment. Prescribers gave permission to contact their patients for participation in the study. Subjects were primarily from the primary care setting with a subsample of psychiatrically referred subjects for comparison. Age- and sex-matched comparators were identified (3:1) from the same pool of prescriber-approved subjects that did not participate. Timely prescription refills (within 37 days) were determined from prescription dates documented in patients' electronic medical record.

RESULTS

Eighty-five percent of SMS intervention patients refilled their prescriptions in a timely manner compared with 62% of patients receiving treatment as usual (OR = 3.46, 95% CI: 1.82, 6.58; p < 0.001). The number needed to treat statistic was computed as five, meaning for every five patients who receive the SMS intervention, we can keep one adherent to their stimulant treatment.

CONCLUSIONS

These preliminary findings support the potential utility of a readily accessible technology to improve the poor rate of adherence to stimulant treatment in children with ADHD. To the best of our knowledge, this study is the first digital health intervention aimed at improving adherence to stimulant medication for children with ADHD. These results support the need for further examination of this technology through more definitive randomized clinical trials.

Trajectories of Growth Associated With Long-Term Stimulant Medication in the Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

To estimate long-term stimulant treatment associations on standardized height, weight, and body mass index trajectories from childhood to adulthood in the Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder (MTA).

METHOD

Of 579 children with DSM-IV ADHD-combined type at baseline (aged 7.0-9.9 years) and 289 classmates (local normative comparison group [LNCG]), 568 and 258 respectively, were assessed 8 times over 16 years (final mean age = 24.7). Parent interview data established subgroups with self-selected Consistent (n = 53, 9%), Inconsistent (n = 374, 66%), and Negligible (n = 141, 25%) stimulant medication use, as well as patients starting stimulants prior to MTA entry (n = 211, 39%). Height and weight growth trajectories were calculated for each subgroup.

RESULTS

Height z scores trajectories differed among subgroups (F = 2.22, p < .0001) and by stimulant use prior to study entry (F = 2.22, p < .001). The subgroup-by-assessment interaction was significant (F = 2.81, p < .0001). Paired comparisons revealed significant subgroup differences at endpoint: Consistent was shorter than Negligible (-0.66 z units /-4.06 cm /1.6 inches, t = -3.17, p < 0.0016), Consistent shorter than Inconsistent (-0.45 z units /-2.74 cm /-1.08 inches, t = -2.39, p < .0172), and the Consistent shorter than LNCG (-0.54 z units/+3.34 cm/ 1.31 inches, t = -3.30, p < 0.001). Weight z scores initially diverged among subgroups, converged in adolescence, and then diverged again in adulthood when the Consistent outweighed the LNCG (+ 3.561 z units /+7.47 kg /+16.46 lb, p < .0001).

CONCLUSION

Compared with those negligibly medicated and the LNCG, 16 years of consistent stimulant treatment of children with ADHD in the MTA was associated with changes in height trajectory, a reduction in adult height, and an increase in weight and body mass index.

CLINICAL TRIAL REGISTRATION INFORMATION

Multimodal Treatment Study of Children With Attention Deficit and Hyperactivity Disorder (MTA); https://clinicaltrials.gov/; NCT00000388.

[Attention-deficit/hyperactivity disorder and substance abuse. Scientific evidence]

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental alteration of biological basis that started in childhood may persist during adolescence-youth and, despite what was believed until not many years ago, also in adulthood up to 50-60% of those affected, producing a significant clinical and psychosocial deterioration. In spite of being a syndrome easily identifiable by the triad: inattention, hyperactivity and impulsivity that characterizes it, in clinical practice there are different circumstances that hinder and complicate its diagnosis and treatment. One of the most significant is the presence, both in childhood and adulthood, of other comorbid mental disorders. It is from adolescence-youth when together with ADHD we can detect the presence of personality, mood and anxiety disorders and especially the use of several substances. The evidences existing until now show how the comorbidity of ADHD and substance use disorder influence the evolutionary course of both, complicating the approach, the treatment and, therefore, aggravating the final prognosis. The difficulties in their approach and the scarcity of treatment options make us underline the importance of preventive treatment in the infantile stage, starting from psychoeducation programs focused on the vulnerability of these patients to substances and the consequences associated with consumption.

Effects of Dexmethylphenidate on Targeted and Non-Targeted Behaviours during Functional Analyses: A Brief Report

Objective: This study evaluated the effects of dexmethylphenidate on problem behavior during functional analyses conducted across dexmethylphenidate and placebo conditions for a child with multiple disabilities. Methods: We conducted functional analyses in a multielement format embedded in a withdrawal design and collected data on the frequency of disruptive behavior and duration of crying. Results: Results suggest disruptive behaviour was maintained by attention when DMPH was absent, but not when it was present. Results also suggest DMPH may have had collateral effects on the probability of non-targeted behaviour (crying). Consistent with previous research, functional analyses exhibited a change in disruptive behaviour's function between medication and placebo conditions. Conclusion: These findings provide further support that stimulant medication may change the function of disruptive behavior and highlight the need to investigate the effects of stimulants on non-targeted behaviors.

Remarkable Reduction of Cocaine Use in Dual Disorder (Adult Attention Deficit Hyperactive Disorder/Cocaine Use Disorder) Patients Treated with Medications for ADHD

Background: Cocaine use disorder (CUD) is a growing public health concern, but so far no effective pharmacotherapies have been demonstrated. Stimulant medications have proved to be promising in CUD treatment. The self-medication hypothesis (SMH) can help to explain this phenomenon better, especially in cases where CUD co-occurs with adult attention deficit hyperactivity disorder (A-ADHD). Methods: In the present retrospective study, a sample of 20 consecutive patients (aged from 18 to 65 years) with dual disorder (A-ADHD/CUD), under treatment with methylphenidate (MPH) or atomoxetine (ATM) medications, was followed to study the effects of A-ADHD treatment on cocaine use. Patients were followed for a mean period of 7 months (minimum 1, maximum 30 months). All individuals were assessed with standardized questionnaires to evaluate diagnosis, treatment efficacy, and clinical improvement. Results: the results showed that behaviors reflecting cocaine addiction were sharply reduced during the stimulant treatment of A-ADHD, and were not correlated with age, gender, familiarity, length of treatment, or medication used. CUD improvement was closely correlated with the A-ADHD improvement. This study supports the validity of the SMH in ADHD patients with co-occurring CUD.

Factors Associated with Attention Deficit Hyperactivity Disorder Medication Use in Community Care Settings

OBJECTIVES

To examine patient- and provider-level factors associated with receiving attention-deficit/hyperactivity disorder (ADHD) medication treatment in a community care setting. We hypothesized that the likelihood of ADHD medication receipt would be lower in groups with specific patient sociodemographic (eg, female sex, race other than white) and clinical (eg, comorbid conditions) characteristics as well as physician characteristics (eg, older age, more years since completing training).

STUDY DESIGN

A retrospective cohort study was conducted with 577 children (mean age, 7.8 years; 70% male) presenting for ADHD to 50 community-based practices. The bivariate relationship between each patient- and physician-level predictor and whether the child was prescribed ADHD medication was assessed. A multivariable model predicting ADHD medication prescription was conducted using predictors with significant (P < .05) bivariate associations.

RESULTS

Sixty-nine percent of children were prescribed ADHD medication in the year after initial presentation for ADHD-related concerns. Eleven of 31 predictors demonstrated a significant (P < .05) bivariate relationship with medication prescription. In the multivariable model, being male (OR, 1.34; 95% CI, 1.01-1.78; P = .02), living in a neighborhood with higher medical expenditures (OR, 1.11 for every $100 increase; 95% CI, 1.03-1.21; P = .005), and higher scores on parent inattention ratings (OR, 1.06; 95% CI, 1.03-1.10; P < .0001) increased the likelihood of ADHD medication prescription.

CONCLUSIONS

We found that some children, based on sociodemographic and clinical characteristics, are less likely to receive an ADHD medication prescription. An important next step will be to examine the source and reasons for these disparities in an effort to develop strategies for minimizing treatment barriers.

Evidence of Low Adherence to Stimulant Medication Among Children and Youths With ADHD: An Electronic Health Records Study

OBJECTIVE

The objective of this study was to evaluate rates and correlates of stimulant medication adherence in a sample of pediatric patients using data derived from electronic medical records (EMRs) from a large health care organization in a large metropolitan area. The study relied on a novel definition of medication adherence as a timely renewal of an index prescription determined using the electronically recorded issuance of a stimulant prescription in the EMR ("refill").

METHODS

Prescription and sociodemographic data were extracted from the Partners HealthCare Research Patient Data Registry to calculate adherence to stimulant medication treatment.

RESULTS

In the EMR, 2,206 patients with prescriptions for central nervous system stimulant medication were identified. Results showed that 46% of the index prescriptions were refilled within the timeframe necessary for the patient to be considered consistently medicated. A multivariable logistic regression model predicting medication adherence from patient demographic and treatment characteristics yielded an area-under-the-curve statistic of 0.57, indicating that these characteristics predicted adherence only modestly better than chance.

CONCLUSIONS

EMR data from a large health care organization showed that 46% of pediatric patients were adherent to treatment with stimulants. Rates of medication adherence were worse among patients receiving care from a primary care provider than among those receiving care from a psychiatrist, in older patients, and in female patients and did not appear to be influenced by racial-ethnic group, economic class, stimulant type, or medication formulation (short or long acting). These findings, which show low rates of medication adherence among children and adolescents with ADHD, suggest the need for efforts to improve these rates.

Investigating the agreement between the clinician and research diagnosis of attention deficit hyperactivity disorder and how it changes over time; a clinical cohort study

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is a common reason for referral to Child and Adolescent Mental Health Services (CAMHS), but families experience long delays between first professional contact and diagnosis, which risks development of secondary impairments. This study explores the agreement between clinician and research diagnoses of ADHD among children attending CAMHS, and their access to interventions. From the limited literature, we anticipated fluctuation and delays, but no other study has focused prospectively on ADHD diagnoses.

METHODS

This was a secondary analysis of a cohort of children attending two CAMHS between 2006 and 2009. The sample included 288 consecutive referrals of children aged between 5 and 11 years. Parents and teachers completed the Development and Well-Being Assessment (DAWBA) when the child was recruited to the study, which provided the research diagnosis of ADHD from the baseline. Clinicians reported no, possible, or definite diagnosis of ADHD and interventions provided at 6-monthly intervals for up to 2 years while the child attended CAMHS. We assessed agreement between the diagnoses using Kendall's Tau-B.

RESULTS

Of the 101 children with a research diagnosis of ADHD, 26 received a definite clinician diagnosis during 2-year follow-up, and 47 received a possible clinician diagnosis. The chance-corrected agreement was poor at all time points (Kendall's Tau-B 0.14-0.48). Clinician diagnoses were unstable, particularly if possible ADHD was recorded at the initial assessment. Of those with a research diagnosis, 15 were prescribed medication and 11 were offered parent training.

CONCLUSIONS

The use of standardised diagnostic assessments could reduce diagnostic uncertainty and increase access to evidence-based interventions.

Prevalence and Predictors of Medication Use in Children with Attention-Deficit/Hyperactivity Disorder: Evidence from a Community-Based Longitudinal Study

OBJECTIVES

To determine, in a community-based sample of primary school-aged children meeting diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD), (1) the proportion of children with ADHD treated with medication; (2) predictors of medication use; and (3) the association between medication use and psychological service utilization.

METHODS

Grade 1 children with ADHD were recruited through 43 schools in Melbourne, Australia, using a two-stage screening and case confirmation procedure. Parent report of medication treatment, clinician diagnosis, and psychological service use were collected at ages 7 and 10 years. Medication use was analyzed by ADHD subtype. Predictors of medication treatment examined included ADHD symptom severity and persistence, externalizing comorbidities, poor academic performance, and social disadvantage. Unadjusted and adjusted logistic regression were used to identify the predictors of medication status.

RESULTS

One hundred seventy-nine children with ADHD were recruited. At baseline, 17.3% had been clinically diagnosed with ADHD, increasing to 37.7% at age 10 years. At baseline, 13.6% were taking ADHD medications, increasing to 25.6% at age 10. Children with the combined and hyperactive-impulsive subtypes were more likely to be taking medication than those with inattentive subtype (age 7: p = 0.002; age 10: p = 0.03). ADHD symptom severity (Conners 3 ADHD Index) at baseline was concurrently and prospectively associated with medication use at both ages (both p = 0.01), and ADHD symptom severity at age 10 was also associated with medication use at age 10 (p = 0.01). Baseline area-level disadvantage was associated with medication use at age 7 (p = 0.04). At 10 years, children receiving medication were more likely, compared with those who were not, to be receiving psychological services (p = 0.001).

CONCLUSIONS

In this study, only a minority of children meeting diagnostic criteria for ADHD were diagnosed clinically or treated with ADHD medication by age 10. The strongest predictors of medication treatment were ADHD symptom severity and area disadvantage.

Changes in Sleep Problems Across Attention-Deficit/Hyperactivity Disorder Treatment: Findings from the Multimodal Treatment of Attention-Deficit/Hyperactivity Disorder Study

Objective: Stimulant medication and behavior therapy are efficacious for youth with attention-deficit/hyperactivity disorder (ADHD). However, research suggests that stimulants may start and/or worsen sleep problems for youth. Further, the impact of behavior therapy for ADHD on sleep is unknown. This study examined the frequency of sleep problems and effects of stimulant medication, behavior therapy, and their combination on sleep problems in youth with ADHD. This study also explored the influence of dimensional baseline ratings of ADHD symptom subtype and psychiatric comorbidity on sleep outcomes. Methods: Participants were 576 children (aged 7-9 years) with ADHD-Combined type from the Multimodal Treatment of ADHD study that compared methylphenidate, behavior therapy, and their combination to community care. Before treatment, parents completed the Child Behavior Checklist used to derive a total sleep problems score. Parents also completed ratings of oppositionality and ADHD symptom severity, whereas youth completed ratings of depression and anxiety. These ratings were readministered after treatment. Results: General linear mixed-effects models were used to assess change in total sleep problems across treatment. The combined group exhibited a statistically significant reduction in total sleep problems (z = -5.81, p < 0.001). Reductions in total sleep problems in methylphenidate (z = -3.11, p = 0.05), behavior therapy (z = -2.99, p = 0.08), or community care (z = -1.59, p > 0.99) did not reach statistical significance. Change in psychiatric symptoms did not significantly moderate change in total sleep problems by treatment assignment. Greater baseline oppositional defiant disorder severity predicted less reduction in total sleep problems, χ²(1) = 3.86, p < 0.05. Conclusions: Findings suggest that combination of methylphenidate and behavior therapy is efficacious for reducing parent-reported sleep problems in young children with ADHD-Combined type relative to community care. However, potential ameliorative effects of monotherapy treatments (i.e., methylphenidate, behavior therapy) should be examined. Future replication is needed to confirm findings.

Continuous performance task in ADHD: Is reaction time variability a key measure?

OBJECTIVE

To compare the use of the Continuous Performance Task (CPT) reaction time variability (intraindividual variability or standard deviation of reaction time), as a measure of vigilance in attention-deficit hyperactivity disorder (ADHD), and stimulant medication response, utilizing a simple CPT X-task vs an A-X-task.

METHOD

Comparative analyses of two separate X-task vs A-X-task data sets, and subgroup analyses of performance on and off medication were conducted.

RESULTS

The CPT X-task reaction time variability had a direct relationship to ADHD clinician severity ratings, unlike the CPT A-X-task. Variability in X-task performance was reduced by medication compared with the children's unmedicated performance, but this effect did not reach significance. When the coefficient of variation was applied, severity measures and medication response were significant for the X-task, but not for the A-X-task.

CONCLUSION

The CPT-X-task is a useful clinical screening test for ADHD and medication response. In particular, reaction time variability is related to default mode interference. The A-X-task is less useful in this regard.

Household Diversion of Prescription Stimulants: Medication Misuse by Parents of Children with Attention-Deficit/Hyperactivity Disorder

OBJECTIVES

The primary objective of this study is to investigate household diversion of stimulant medication. Secondary objectives are to examine clinical/demographic predictors of diversion, types of formulations diverted, exposure to household diversion in the media, and storage of prescription stimulants within households.

METHODS

Questionnaires were completed by 180 parents of youth who were currently taking stimulant medication for treatment of attention-deficit/hyperactivity disorder (ADHD). Parents were asked whether they or another adult in the home had ever taken their child's stimulant medication or given one child's stimulant medication to another child in the home. Additionally, data regarding demographics, parental ADHD (diagnosed or suspected), past suspicions of missing medication, and medication storage were also collected. Responses were compared using Pearson's chi-squared test with Yates' continuity correction.

RESULTS

Sixteen percent of parents reported diversion of stimulant medication to another household member, with the majority admitting to taking the medication themselves. Another 13% had been tempted to illicitly self-administer their child's medication. Parents with suspected or diagnosed ADHD showed greater risk of self-administration or temptation to do so, compared to parents without (33% vs. 17%, p = 0.01). The majority of parents (71%) stored prescription stimulants "in plain sight," or "out of sight but available to all."

CONCLUSION

Although previous research has focused on peer diversion among adolescents and young adults, clinicians must be vigilant for the possibility of diversion by parents of children treated with stimulant medication.

Adults with Attention Deficit Hyperactivity Disorder Report High Symptom Levels of Troubled Sleep, Restless Legs, and Cataplexy

Objective: To compare the occurrence of a spectrum of different self-reported sleep problems in adults with ADHD and a control group, and to study the impact of current ADHD medication use and clinical ADHD subtype.

Method: Cross-sectional study of 268 clinically ascertained adult ADHD patients (DSM-IV criteria) and 202 randomly selected controls. Sleep problems were self-reported using validated questions, partly from Global Sleep Assessment Questionnaire.

Results: ADHD patients reported more sleep problems than controls: Lifetime occurrence of sleep problems (82.6 vs. 36.5%), hypnotics use (61.4 vs. 20.2%), current sleep duration below 6 h (26.6 vs. 7.6%), and symptoms/signs during the past 4 weeks of excessive daytime sleepiness, cataplexy, loud snoring, breathing pauses during sleep, restless legs, and periodic limb movements in sleep (significant odds ratios ranged from 1.82 to 14.55). Current ADHD medication use was associated with less cataplexy compared with not using medication. Patients with inattentive subtype reported better sleep quality and less restless legs than patients with hyperactive/impulsive subtypes.

Conclusions: Adults with ADHD reported a very high occurrence of many different self-reported sleep problems, underlining the importance of screening for sleep disorders. Among the ADHD patients, medication use was not associated with more sleep-related symptoms, but in fact less cataplexy. When comparing ADHD subtypes, the inattentive subtype was associated with less sleep problems.

Acute Effects of MPH on the Parent-Teen Interactions of Adolescents With ADHD

This study explored the nature of interactions between adolescent males with ADHD and their mothers, and the effects of methylphenidate (MPH) on an analogue parent-teen interaction task. Twenty-five adolescent males with ADHD ( M = 13.6 years) and their mothers and 14 non-ADHD adolescent males ( M = 13.4 years) and their mothers completed ratings of perceived dyadic conflict. Behavioral observations of dyads during 10-min conflict-resolution tasks were also collected. The ADHD dyads completed these tasks twice, with adolescents receiving either 0.3 mg/kg MPH or placebo. Videotaped sessions were coded using the Parent-Adolescent Interaction Rating Scale. Following the conflict-resolution task, participants rated their perceived conflict and affect during the interaction. Findings indicated higher conflict in the ADHD dyads, and minimal MPH effects on parent-teen interactions during the analogue task. Results suggest that stimulant medication does not produce meaningful acute effects on parent-teen interactions.

Comparing Auditory Noise Treatment with Stimulant Medication on Cognitive Task Performance in Children with Attention Deficit Hyperactivity Disorder: Results from a Pilot Study

Background: Recent research has shown that acoustic white noise (80 dB) can improve task performance in people with attention deficits and/or Attention Deficit Hyperactivity Disorder (ADHD). This is attributed to the phenomenon of stochastic resonance in which a certain amount of noise can improve performance in a brain that is not working at its optimum. We compare here the effect of noise exposure with the effect of stimulant medication on cognitive task performance in ADHD. The aim of the present study was to compare the effects of auditory noise exposure with stimulant medication for ADHD children on a cognitive test battery. A group of typically developed children (TDC) took the same tests as a comparison.

Methods: Twenty children with ADHD of combined or inattentive subtypes and twenty TDC matched for age and gender performed three different tests (word recall, spanboard and n-back task) during exposure to white noise (80 dB) and in a silent condition. The ADHD children were tested with and without central stimulant medication.

Results: In the spanboard- and the word recall tasks, but not in the 2-back task, white noise exposure led to significant improvements for both non-medicated and medicated ADHD children. No significant effects of medication were found on any of the three tasks.

Conclusion: This pilot study shows that exposure to white noise resulted in a task improvement that was larger than the one with stimulant medication thus opening up the possibility of using auditory noise as an alternative, non-pharmacological treatment of cognitive ADHD symptoms.

Effects of Methylphenidate on Sleep Functioning in Children with Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

To examine the effects of stimulant medication on the sleep functioning of children with attention-deficit/hyperactivity disorder (ADHD) and identify predictors of sleep problems as a side effect of taking stimulant medication.

METHOD

One hundred sixty-three stimulant-naïve children (72% boys) aged 7 to 11 years diagnosed with ADHD (120 with ADHD predominantly inattentive type, 43 with ADHD combined type) participated in a 4-week, randomized, double-blind, placebo-controlled trial of once-daily (long-acting) methylphenidate (MPH). Parents completed weekly side-effect ratings including an item related to sleep problems.

RESULTS

Ten percent of patients had parent-rated sleep problems before the initiation of medication. Rates of parent-rated sleep problems during MPH titration generally increased with increasing MPH dose (placebo: 8%; low dose: 18%; medium dose: 15%; high dose: 25%). Differences emerged between children with (n = 16) or without (n = 147) preexisting sleep problems. Although 23% of children without preexisting sleep problems went on to have sleep problems at the highest MPH dose, only 37.5% of children with preexisting sleep problems still had sleep problems at the highest MPH dose. Lower weight and lower body mass index (BMI) were associated with increased sleep problems during MPH titration.

CONCLUSION

This study demonstrated a general association between increased MPH dose and increased sleep problems in children with ADHD, particularly for children of lower weight/BMI. However, a substantial proportion of children with preexisting sleep difficulties no longer had sleep problems on the highest MPH dose, which may help explain mixed findings reported to date in studies examining the impact of MPH on sleep functioning in children with ADHD and suggests that MPH dose titration should not be avoided solely on the basis of a child's premorbid sleep problems. Future research is needed to replicate and extend these findings to more specific domains of sleep functioning and to identify differences between children with persistent or improved sleep functioning as a result of MPH use.

Stimulant medication effects on growth and bone age in children with attention-deficit/hyperactivity disorder: a prospective cohort study

Stimulant medication is known to cause transient weight loss and slowing down of growth, but whether it delays physical maturation is unclear. We studied growth and bone age over the first 3 years of treatment in children with attention-deficit/hyperactivity disorder (patients) compared with healthy siblings (controls). Bone age was estimated blindly by two independent radiologists using Tanner and Whitehouse version 3. Dexamphetamine or methylphenidate was titrated and continued when clinically indicated. Forty out of 73 patients, together with 22 controls, completed the study. There were no significant growth differences between the two groups at baseline. Despite slower growth on treatment [5.1 cm/year, 95% confidence interval (CI): 4.7-5.5, vs. 6.3 cm/year, 95% CI: 5.7-6.8, P=0.002; and 2.7 kg/year, 95% CI: 2.1-3.3, vs. 4.4 kg/year, 95% CI: 3.5-5.3, P=0.005], the patients showed no significant maturational delay (RUS score: 49 U/year, 95% CI: 44-55, vs. 55 U/year, 95% CI: 47-63, P=0.27). A subgroup of patients underwent serial biochemistry and dual-energy X-ray absorptiometry, recording a significant reduction in fat (5.61±3.56-4.22±3.09 kg, P<0.001) and leptin (3.88±2.87-2.57±1.94 ng/ml, P=0.017). The pattern of change in height z-score over time was modified by the dose of medication (P for interaction=0.024). We found no medication effect on the rate of maturation, which was instead predicted by baseline leptin (P=0.035 controlling for age and sex).

Does intensive multimodal treatment for maternal ADHD improve the efficacy of parent training for children with ADHD? A randomized controlled multicenter trial

BACKGROUND

This is the first randomized controlled multicenter trial to evaluate the effect of two treatments of maternal attention-deficit hyperactivity disorder (ADHD) on response to parent-child training targeting children's external psychopathology.

METHODS

Mother-child dyads (n = 144; ADHD according to DSM-IV; children: 73.5% males, mean age 9.4 years) from five specialized university outpatient units in Germany were centrally randomized to multimodal maternal ADHD treatment [group psychotherapy plus open methylphenidate medication; treatment group (TG): n = 77] or to clinical management [supportive counseling without psychotherapy or psychopharmacotherapy; control group (CG): n = 67]. After 12 weeks, the maternal ADHD treatment was supplemented by individual parent-child training for all dyads. The primary outcome was a change in the children's externalizing symptom scores (investigator blinded to the treatment assignment) from baseline to the end of the parent-child training 6 months later. Maintenance therapy continued for another 6 months. An intention-to-treat analysis was performed within a linear regression model, controlling for baseline and center after multiple imputations of missing values.

RESULTS

Exactly, 206 dyads were assessed for eligibility, 144 were randomized, and 143 were analyzed (TG: n = 77; CG: n = 66). After 6 months, no significant between-group differences were found in change scores for children's externalizing symptoms (adjusted mean TG-mean CG=1.1, 95% confidence interval -0.5-2.7; p = .1854), although maternal psychopathology improved more in the TG. Children's externalizing symptom scores improved from a mean of 14.8 at baseline to 11.4 (TG) and 10.3 (CG) after 6 months and to 10.8 (TG) and 10.1 (CG) after 1 year. No severe harms related to study treatments were found, but adverse events were more frequent in TG mothers than in CG mothers.

CONCLUSIONS

The response in children's externalizing psychopathology did not differ between maternal treatment groups. However, multimodal treatment was associated with more improvement in maternal ADHD. Child and maternal treatment gains were stable (CCT-ISRCTN73911400).

Persistent Handwriting Difficulties in Children With ADHD After Treatment With Stimulant Medication

OBJECTIVE

Children with ADHD often present with handwriting difficulties. However, the extent to which motor and attention skills influence performance in this group has not yet been explored. The objective of this study was to examine the factors associated with change in handwriting performance.

METHOD

This study examines the factors associated with change in handwriting performance of 49 children newly diagnosed with ADHD (mean age = 8.4 [SD=1.3] years) prior to and 3 months following use of a stimulant medication.

RESULTS

Handwriting legibility and speed improved significantly at follow-up evaluation. However, most of the children with legibility difficulties at baseline continued to demonstrate difficulties when evaluated 3 months after initiation of medication. Change in handwriting legibility was best determined by improvements in visual-motor integration skills (β = 0.07-0.10; p < .001), while the change in speed did not appear to be consistently related to a single factor.

CONCLUSION

Handwriting difficulties are common in children with ADHD, and medication alone is not sufficient to resolve these challenges.

Psychopharmacological treatment of ADHD in adults aged 50+: an empirical study

OBJECTIVE

To study pharmacotherapy in adults aged 50+ with ADHD.

METHOD

A survey was administered to adults with ADHD (≥ 50 years old). Participants on medication for ADHD were compared with those not on medications.

RESULTS

Mean age of participants was 55.8 years, and mean age when diagnosed with ADHD was 50.3 years. Ninety-five participants (63.8%) reported current psychopharmacological treatment for ADHD, 36 (24.2%) had stopped psychopharmacological treatment, and 18 (12.0%) were psychopharmacological treatment naive for ADHD. Those currently being treated psychopharmacologically for ADHD reported significantly improved attention relative to the two nonmedicated groups (p < .01). Among examined sample characteristics (including current psychopharmacological treatment for ADHD), employment was associated with a better outcome (odds ratio = 3.3, p = .006).

CONCLUSION

The majority of adults aged 50+ with ADHD reported regular pharmacotherapy for ADHD. Participants currently receiving psychopharmacological treatment for ADHD reported better attention than those not receiving pharmacotherapy. Employment was associated with more favorable outcomes.

Stimulant use in patients with sturge-weber syndrome: safety and efficacy

BACKGROUND

Sturge-Weber syndrome is characterized by a facial port-wine birthmark, vascular eye abnormalities, and a leptomeningeal angioma. Attention and behavioral issues are common in Sturge-Weber syndrome. However, literature evidence for stimulant treatment is minimal. This study evaluates stimulant medication safety and efficacy in individuals with Sturge-Weber syndrome.

METHODS

The research database of the Hunter Nelson Sturge-Weber Center (n = 210 subjects in the database) was reviewed for stimulant use. Twelve patients (mean age 10.5 years, age range 4 to 21 years) on stimulants were seen between 2003 and 2012. A retrospective chart review obtained comorbid diagnoses, stimulant type and dosage, medication side effects, vital signs, and medication efficacy.

RESULTS

All 12 patients had brain involvement (unilateral, nine; bilateral, three). Additional comorbidities included epilepsy (twelve), hemiparesis (eight), headaches (eight), and vision deficits (six). Eight patients reported side effects, primarily appetite suppression (four) and headaches (three). There were no statistically significant changes in weight or blood pressure 6 months after medication initiation. Medication efficacy was subjectively reported in 11 patients. Seven patients remained on stimulants at their most recent follow-up visit.

CONCLUSIONS

This study preliminarily evaluates stimulant medication use in a small group of Sturge-Weber syndrome patients. Stimulants were tolerated and effective in most subjects. Side effects were mostly minor and medication did not negatively affect growth or vital signs. Stimulant medication may be a safe and effective intervention for Sturge-Weber syndrome children with attention issues/attention deficit hyperactivity disorder. Further studies with larger sample sizes are needed.

Attention-deficit/hyperactivity disorder and substance abuse

Attention-deficit/hyperactivity disorder (ADHD) and substance use disorders are inextricably intertwined. Children with ADHD are more likely than peers to develop substance use disorders. Treatment with stimulants may reduce the risk of substance use disorders, but stimulants are a class of medication with significant abuse and diversion potential. The objectives of this clinical report were to present practical strategies for reducing the risk of substance use disorders in patients with ADHD and suggestions for safe stimulant prescribing.

Paediatricians' decision making about prescribing stimulant medications for children with attention-deficit/hyperactivity disorder

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is now the most common reason for a child to present to a paediatrician in Australia. Stimulant medications are commonly prescribed for children with ADHD, to reduce symptoms and improve function. In this study we investigated the factors that influence paediatricians' decisions about prescribing stimulant medications.

METHOD

In-depth, semi-structured interviews were conducted with paediatricians (n = 13) who were purposively recruited so as to sample a broad demographic of paediatricians working in diverse clinical settings. Paediatricians were recruited from public outpatient and private paediatrician clinics in Victoria, Australia. The interviews were audio-recorded and transcribed verbatim for thematic analysis. Paediatricians also completed a questionnaire describing their demographic and practice characteristics.

RESULTS

Our findings showed that the decision to prescribe is a dynamic process involving two key domains: (1) weighing up clinical factors; and (2) interacting with parents and the patient along the journey to prescribing. Five themes relating to this process emerged from data analysis: comprehensive assessments that include history, examination and information from others; influencing factors such as functional impairment and social inclusion; previous success; facilitating parental understanding including addressing myths and parental confusion; and decision-making model.

CONCLUSIONS

Paediatricians' decisions to prescribe stimulant medications are influenced by multiple factors that operate concurrently and interdependently. Paediatricians do not make decisions about prescribing in isolation; rather, they actively involve parents, teachers and patients, to arrive at a collective, well-informed decision.

The attention deficit hyperactivity disorder phenotype as a summation of deficits in executive functioning and reward sensitivity: does this explain its relationship with oppositional defiant disorder?

OBJECTIVE

Attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) commonly coexist but the relationship between them has not been well explained. We present a view of the ADHD phenotype as a summation of deficits in executive functioning and reward sensitivity and apply this to explain its co-occurrence with ODD.

MODEL

ADHD relates to difficulty in sustaining concentration for completing tasks. This is associated with lack of reward due to lack of achievement. The unfavorable balance of effort to reward in ADHD is exacerbated in ODD, a condition in which lack of reward is responsible for an adverse effect on mood resulting in a negative attitude and oppositional behavior. We have called this model the "Mental effort-reward imbalances model".

CONCLUSION

This model predicts that oppositional symptoms would be highly prevalent in ADHD, to the extent that ODD would be a frequent co-morbidity.

Cerebellar morphology and the effects of stimulant medications in youths with attention deficit-hyperactivity disorder

The cerebellum is emerging as a key anatomical structure underlying normal attentional and cognitive control mechanisms. Dysregulation within cerebellar circuits may contribute to the core symptoms of Attention Deficit/Hyperactivity Disorder (ADHD). In the present study we aimed to characterize surface morphological features of the cerebellum in ADHD and healthy comparison youths. Further, we studied the association of cerebellar morphology with the severity of ADHD symptoms and the effects of stimulant treatment. We examined 46 youths with ADHD and 59 comparison youths 8-18 years of age in a cross-sectional, case-control study using magnetic resonance imaging. Measures of cerebellar surface morphology were the primary outcome. Relative to comparison participants, youths with ADHD exhibited smaller regional volumes corresponding to the lateral surface of the left anterior and the right posterior cerebellar hemispheres. Stimulant medication was associated with larger regional volumes over the left cerebellar surface, whereas more severe ADHD symptoms were associated with smaller regional volumes in the vermis. We used optimized measures of morphology to detect alterations in cerebellar anatomy specific to ADHD, dimensions of symptomology, and stimulant treatment. Duration of treatment correlated positively with volumes of specific cerebellar subregions, supporting a model whereby compensatory morphological changes support the effects of stimulant treatment.

Motivational incentives and methylphenidate enhance electrophysiological correlates of error monitoring in children with attention deficit/hyperactivity disorder

BACKGROUND

Children with attention deficit hyperactivity disorder (ADHD) are characterised by developmentally inappropriate levels of hyperactivity, impulsivity and/or inattention and are particularly impaired when performing tasks that require a high level of cognitive control. Methylphenidate (MPH) and motivational incentives may help improve cognitive control by enhancing the ability to monitor response accuracy and regulate performance accordingly.

METHODS

Twenty-eight children with DSM-IV ADHD (combined type) aged 9-15 years and pairwise-matched typically developing children (CTRL) performed a go/no-go task in which the incentives attached to performance on no-go trials were manipulated. The ADHD group performed the task off and on their usual dose of MPH. CTRL children performed the task twice but were never medicated. EEG data were recorded simultaneously and two electrophysiological indices of error monitoring, the error-related negativity (ERN) and error positivity (Pe) were measured. Amplitudes of each ERP were compared between diagnostic groups (CTRL, ADHD), medication days (Off MPH, On MPH) and motivational conditions (baseline - low incentive, reward, response cost).

RESULTS

Error rates were lower in the reward and response cost conditions compared with baseline across diagnostic groups and medication days. ERN and Pe amplitudes were significantly reduced in ADHD compared with CTRL, and were significantly enhanced by MPH. Incentives significantly increased ERN and Pe amplitudes in the ADHD group but had no effect in CTRL. The effects of incentives did not interact with the effects of MPH on either ERP. Effect sizes were computed and revealed larger effects of MPH than incentives on ERN and Pe amplitudes.

CONCLUSIONS

The findings reveal independent effects of motivational incentives and MPH on two electrophysiological markers of error monitoring in children with ADHD, suggesting that each may be important tools for enhancing or restoring cognitive control in these children.

Prevention of serious conduct problems in youth with attention deficit/hyperactivity disorder

The purpose of this review is to discuss issues in the prevention of serious conduct problems among children and adolescents with attention deficit/hyperactivity disorder (ADHD). The authors began by reviewing research on the common genetic and environmental etiological factors, developmental trajectories, characteristics and impairments associated with ADHD and comorbid oppositional defiant and conduct disorders. Next, the authors presented empirically based models for intervention with children and adolescents with ADHD that are at risk of developing serious conduct problems and detailed the evidence supporting these models. Researchers have demonstrated the utility of medication and psychosocial intervention approaches to treat youth with these problems, but current evidence appears to support the superiority of multimodal treatments that include both approaches. Future directions for researchers are discussed.

Abnormal amygdalar activation and connectivity in adolescents with attention-deficit/hyperactivity disorder

OBJECTIVE

Emotional reactivity is one of the most disabling symptoms associated with attention-deficit/hyperactivity disorder (ADHD). We aimed to identify neural substrates associated with emotional reactivity and to assess the effects of stimulants on those substrates.

METHOD

We used functional magnetic resonance imaging (fMRI) to assess neural activity in adolescents with (n = 15) and without (n = 15) ADHD while they performed a task involving the subliminal presentation of fearful faces. Using dynamic causal modeling, we also examined the effective connectivity of two regions associated with emotional reactivity, i.e., the amygdala and the lateral prefrontal cortex (LPFC). The participants with ADHD underwent scanning both on and off stimulant medication in a counterbalanced fashion.

RESULTS

During the task, we found that activity in the right amygdala was greater in adolescents with ADHD than in control subjects. In addition, in adolescents with ADHD, greater connectivity was detected between the amygdala and LPFC. Stimulants had a normalizing effect on both the activity in the right amygdala and the connectivity between the amygdala and LPFC.

CONCLUSIONS

Our findings demonstrate that in adolescents with ADHD, a neural substrate of fear processing is atypical, as is the connectivity between the amygdala and LPFC. These findings suggest possible neural substrates for the emotional reactivity that is often present in youths with ADHD, and provide putative neural targets for the development of novel therapeutic interventions for this condition.

Effects of motivation and medication on electrophysiological markers of response inhibition in children with attention-deficit/hyperactivity disorder

BACKGROUND

Theories of attention-deficit/hyperactivity disorder (ADHD) posit either executive deficits and/or alterations in motivational style and reward processing as core to the disorder. Effects of motivational incentives on electrophysiological correlates of inhibitory control and relationships between motivation and stimulant medication have not been explicitly tested.

METHODS

Children (9-15 years) with combined-type ADHD (n = 28) and matched typically developing children (CTRL) (n = 28) performed a go/no-go task. Electroencephalogram data were recorded. Amplitude of two event-related potentials, the N2 and P3 (markers of response conflict and attention), were measured. The ADHD children were all stimulant responders tested on and off their usual dose of methylphenidate; CTRLs were never medicated. All children performed the task under three motivational conditions: reward; response cost; and baseline, in which points awarded/deducted for inhibitory performance varied.

RESULTS

There were effects of diagnosis (CTRL > ADHD unmedicated), medication (on > off), and motivation (reward and/or response cost > baseline) on N2 and P3 amplitude, although the N2 diagnosis effect did not reach statistical significance (p = .1). Interactions between motivation and diagnosis/medication were nonsignificant (p > .1).

CONCLUSIONS

Motivational incentives increased amplitudes of electrophysiological correlates of response conflict and attention in children with ADHD, towards the baseline (low motivation) amplitudes of control subjects. These results suggest that, on these measures, motivational incentives have similar effects in children with ADHD as typically developing CTRLs and have additive effects with stimulant medication, enhancing stimulus salience and allocation of attentional resources during response inhibition.

Predicting methylphenidate response in long-term survivors of childhood cancer: a randomized, double-blind, placebo-controlled, crossover trial

OBJECTIVE

To investigate the methylphenidate (MPH) response rate among childhood survivors of acute lymphoblastic leukemia (ALL) and brain tumors (BTs) and to identify predictors of positive MPH response.

METHODS

Cancer survivors (N = 106; BT = 51 and ALL = 55) identified as having attention deficits and learning problems participated in a 3-week, double-blind, crossover trial consisting of placebo, low-dose MPH (0.3 mg/kg), and moderate-dose MPH (0.6 mg/kg). Weekly teacher and parent reports on the Conners' Rating Scales were gathered.

RESULTS

Following moderate MPH dose, 45.28% of the sample was classified as responders. Findings revealed that more problems endorsed prior to the medication trial on parent and teacher ratings were predictive of positive medication response (p < .05).

CONCLUSIONS

MPH significantly reduces attention problems in a subset of childhood cancer survivors. Parent and teacher ratings may assist in identifying children most likely to respond to MPH so prescribing may be optimally targeted.

Effects of stimulant medication under varied motivational operations

We evaluated the evocative effects of four conditions (high- and low-preference activities, low and divided attention) and stimulant medication on the behavior of a 16-year-old boy with attention deficit hyperactivity disorder and moderate mental retardation. All behavior (activity engagement, activity changes, inappropriate touching, rude behaviors, and physical aggression) improved with stimulant medication in most conditions, but undesirable behaviors were not reduced to acceptable levels in all conditions. This finding suggests that stimulant medication may be a valuable adjunct to function-based interventions.

Neurofibromatosis and Attentional Deficits: An Illustrative Example of the Common Association of Medical Causes with Behavioural Syndromes, Implications for General Child Mental Health Services

   Neurofibromatosis type 1 (NF1) is a common autosomal dominant gene disorder. In addition to well described physical and cognitive features certain behavioural patterns have been reported. Clear association has been shown between NF1 and attention deficit hyperactivity disorder (ADHD), with up to half of children with NF1 fulfilling DSM-IV diagnostic criteria for ADHD. This article aims to increase awareness among child mental health workers of the common link between genetic conditions (like NF1) and ADHD, thus improving diagnosis and intervention.

Stimulant treatment patterns and compliance in children and adults with newly treated attention-deficit/hyperactivity disorder

OBJECTIVE

To identify newly treated cases of attention-deficit/hyperactivity disorder (ADHD), assess the presence of comorbid psychiatric conditions, identify pharmacological treatment patterns, and examine treatment compliance rates among children and adults with newly diagnosed and pharmacologically treated ADHD in a managed care population.

METHODS

Children (aged 18 years or younger) and adults having newly treated ADHD were identified from medical and pharmacy claims in an administrative claims database from 6 health plans. Claims data for services or products provided between April 1, 1997, and September 30, 1999, was analyzed for the managed care population (604,538 children and 1,542,304 adults). Data on compliance, persistence, and pharmacological treatment patterns were collected for the 6 months prior to and the 18 months following each patient.s initial ADHD pharmacological treatment. A medication possession ratio (MPR) was calculated by dividing the number of days supplied in a prescription by the number of days until the next prescription was filled. Compliance was defined as an MPR >0.8 and persistence as an MPR >0.3.

RESULTS

The prevalence of diagnosed ADHD in this population was 0.7% (11,962 [2%] of children and 2,636 [0.2%] of adults) and incidence of ADHD was 0.04% (735 [0.1%] of children and 162 [0.01%] of adults). The most common comorbid psychiatric condition for incident cases was depression (31.6% of children and 63% of adults). Few children and adults switched their initial ADHD treatment agent, 11% and 12%, respectively. Dose titration occurred in 67% of children and 54% of adults. On average, changes in treatment (switching, titrating) took place after 2 to 3 months of treatment. Although patients, on average, obtained more than 6 refills for a total 200 days supply, the majority of patients (84% of children and 88% of adults) were compliant for less than 2 months over the period they were refilling prescriptions.

CONCLUSION

Although the majority of patients had dosage changes, these changes typically occurred after several months of treatment. Results suggest that, even though patients continued their ADHD medication for several months, they did not consistently take medication for more than 2 months. Given these treatment patterns, pharmacologic treatment in newly treated ADHD patients may be suboptimal and may impact outcomes, including the effectiveness and cost of treatment.

Who first suggests the diagnosis of attention-deficit/hyperactivity disorder?

PURPOSE

We wanted to survey physicians in the Washington, DC, metropolitan area regarding the frequency with which physicians, teachers, parents, and others first suggest the diagnosis of attention-deficit/hyperactivity disorder (ADHD).

METHODS

A questionnaire was mailed to all family physicians, primary care pediatricians, and child psychiatrists in greater Washington, DC. In answer to the question, "Who first suggests the diagnosis of ADHD?" respondents assigned percentages to primary care physicians, consultants, parents, teachers, etc.

RESULTS

Teachers were most likely to be first to suggest the diagnosis of ADHD (46.4%; 95% CI, 44.1%-48.7%), followed by parents (30.2%; 95% CI, 28.3%-32.0%), primary care physicians (11.3%; 95% CI, 9.7%-12.8%), school personnel other than teachers (6.0%; 95% CI, 4.9%-7.2%), consultants such as child psychiatrists or psychologists (3.1%; 95% CI, 2.3%-3.9%) and other specified categories (3.0%; 95% CI, 2.4%-3.6%).

CONCLUSIONS

Teachers and other school personnel are often the first to suggest the diagnosis of ADHD in children in the greater Washington, DC, area. Regional variations in the prescribing of medication for ADHD may be caused at least in part by variations in the likelihood of a teacher suggesting the diagnosis of ADHD.