Pharmacotherapy for ADHD in children and adolescents: A summary and overview of different European guidelines

Attention deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by a persistent pattern of inattention, hyperactivity, and impulsivity. It is the most common neurodevelopmental disorder presenting to pediatric services, and pediatricians are often involved in the early assessment, diagnosis, and treatment of children with ADHD. The treatment of ADHD typically involves a multimodal approach that encompasses a combination of psychoeducation, parent/teacher training, psychosocial/psychotherapeutic interventions, and pharmacotherapy. Concerning pharmacotherapy, guidelines vary in drug choice and sequencing, with psychostimulants, such as methylphenidate and (lis)dexamfetamine, generally being the favored initial treatment. Alternatives include atomoxetine and guanfacine. Pharmacotherapy has been proven effective, but close follow-up focusing on physical growth, cardiovascular monitoring, and the surveillance of potential side effects including tics, mood fluctuations, and psychotic symptoms, is essential. This paper presents an overview of current pharmacological treatment options for ADHD and explores disparities in treatment guidelines across different European countries.   Conclusion: Pharmacological treatment options for ADHD in children and adolescents are effective and generally well-tolerated. Pharmacotherapy for ADHD is always part of a multimodal approach. While there is a considerable consensus among European guidelines on pharmacotherapy for ADHD, notable differences exist, particularly concerning the selection and sequencing of various medications. What is Known: • There is a significant base of evidence for pharmacological treatment for ADHD in children and adolescents. • Pediatricians are often involved in assessment, diagnosis and management of children with ADHD. What is New: • Our overview of different European guidelines reveals significant agreement in the context of pharmacotherapy for ADHD in children and adolescents. • Discrepancies exist primarily in terms of selection and sequencing of different medications.

Prospective observational study protocol to investigate long-term adverse effects of methylphenidate in children and adolescents with ADHD: the Attention Deficit Hyperactivity Disorder Drugs Use Chronic Effects (ADDUCE) study

INTRODUCTION

Methylphenidate is the most frequently used medication for the treatment of attention-deficit/hyperactivity disorder (ADHD) in Europe. Following concerns about its safety, the European Commission called for research into the long-term effects of methylphenidate on children and adolescents with ADHD. The Attention Deficit Hyperactivity Disorder Drugs Use Chronic Effects (ADDUCE) research programme was designed to address this call. At the heart of this programme is a 2-year longitudinal naturalistic pharmacovigilance study being conducted in 27 European sites.

METHODS AND ANALYSIS

3 cohorts of children and adolescents (aged 6-17) living in the UK, Germany, Italy and Hungary are being recruited:Group 1 (Medicated ADHD): 800 ADHD medication-naive children and adolescents with a clinical diagnosis of ADHD about to start methylphenidate treatment for the first time.Group 2 (Unmedicated ADHD): 400 children and adolescents with a clinical diagnosis of ADHD who have never been treated with ADHD medication and have no intention of beginning medication.Group 3 (Non-ADHD): 400 children and adolescents without ADHD who are siblings of individuals in either group 1 or 2.All participants will be assessed 5 times during their 2-year follow-up period for growth and development, psychiatric, neurological and cardiovascular health. The primary outcome measure will be the height velocity SD score.

ETHICS AND DISSEMINATION

Ethical approval for the study has been granted by the East of Scotland Research Ethics Service. Following this approval, patient information leaflets and consent forms were translated as necessary and submissions made by lead sites in each of the other 3 countries to their own ethics committees. Following ethical approval in each country, local ethical permissions at each site were sought and obtained as needed. The study's website (http://www.adhd-adduce.org/page/view/2/Home) provides information for researchers, participants and the general public.

TRIAL REGISTRATION NUMBER

NCT01470261.

[Lisdexamfetamine dimesylate: a Treatment Option for Children and Adolescents with Attention Deficit/Hyperactivity Disorder in Germany and Across Europe]

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder - which may persist into adolescence and adulthood. Psychostimulants and atomoxetine (ATX) are frequently prescribed to treat ADHD in Germany. Lisdexamfetamine dimesylate (LDX) is the most recently approved ADHD medication in Germany and other European countries. Data used to support the European registration of LDX is summarised from three phase-3/3b studies in children and adolescents with ADHD. Short-term efficacy (study SPD489 - 325), maintenance of efficacy (study SPD489 - 326) and efficacy in patients who had previously responded inadequately to methylphenidate (MPH) treatment (study SPD489 - 317) were demonstrated. The safety and tolerability profile of LDX in all three European studies was shown to be in line with that of other psychostimulants used to treat patients with ADHD.

High rate of non-eligibility: methodological factors impacting on recruitment for a multicentre, double-blind study of paediatric patients with major depressive disorder

INTRODUCTION

This report describes difficulties encountered when attempting to recruit children and adolescents with major depression for a recent international double-blind, placebo-controlled trial (www.clinicaltrials.gov Nr. NCT00849901).

METHODS

Over a 14-month period, children and adolescents with depressive symptoms were pre-screened for their eligibility for inclusion.

RESULTS

85 patients (age 7-17 years) were considered. Of these, only one was enrolled. The main reasons for non-eligibility were: failure to meet the baseline severity criterion on the primary outcome scale (clinical global impression-severity; 32.1% of the patients); requirement for immediate hospitalisation (15.4%); or the presence of an exclusionary comorbid psychiatric disorder (19.1%).

DISCUSSION

The recruitment of paediatric patients with major depression was primarily limited by various inclusion and exclusion criteria. Slow recruitment of small patient samples may impact strongly on the representativeness and generalisability of research findings, and thus on analyses in evidence-based medicine and on the development and recommendations of treatment guidelines. This may impact in turn on the feasibility of the clinical development and registration process of new compounds in paediatric psychopharmacology and beyond.

[Value of acoustic speech analysis for prognostic assessment of stuttering in children. Partial results of a prospective longitudinal study]

PRESENT STATE OF KNOWLEDGE: There are currently no known acoustic parameters by which stuttering children can be appraised which will predict their subsequent speech fluency.

AIM

To explain the significance of factors which perpetuate stuttering by using computer-based speech analysis of fluent speech for a 1 1/2 year period and to relate acoustic analysis with clinical measurements of stuttering. Special attention was given to motor-oral and/or linguistic deficits.

METHOD AND RESULTS

A prospective study of 58 pre-school children who stutter. Correlations were sought between acoustic variables in the severity and course of the stuttering with the influence of motor-oral and linguistic disturbances. 19 age-matched, normal-speaking children served as controls. A subdivision of the study group into different subgroups with particular motor-oral and/or linguistic problems showed that children whose stuttering coincides with a delayed speech development have a distinctly better prognosis for early remission. In most of these children the stuttering remitted to such a degree as the deficits causing the stuttering could be reappraised, which means simultaneous improvement of the linguistic competence.

CONCLUSION

It was apparent that remission rate was much higher in those children who showed linguistic disturbances at the same time with stuttering. Within the stuttering group, subgroups showed a few correlations in several acoustic parameters, but these could not, as yet, be shown to give any prognostic markers in the routine diagnosis of children who stutter. If a child shows any danger-signs of acquiring stuttering on a more permanent basis, a careful diagnosis is necessary in order to find the individually underlying factors before any therapeutical procedure.

Stuttering in childhood: a five-year longitudinal study in progress

The actual state of research in childhood stuttering is presented and certain points open to criticism are discussed. We want to find answers to some of the open questions by means of a longitudinal study that starts at an early stage. In this study the prognostic validity of various dimensions of behaviour can be determined with regard to the development of stuttering. Thus, the conditions for the development of a valid and reliable instrument for early diagnosis are created that enable the specialist to estimate the probability of chronicity and to determine whether to treat or not to treat childhood stuttering. Furthermore, the study aims to develop a screening procedure which is easy to use for the persons in the child's surroundings (parents, teachers, physicians) so that stuttering children can be referred to a specialist at an earlier stage.

[Stuttering in childhood: etiology and follow-up. Initial results of a 5-year longitudinal study]

For about 15 months a multifactorial longitudinal study on the development of stuttering in preschool children has been conducted at the Phoniatric Outpatient Department of the University of Ulm. The main subject of the study is to determine valid indicators to estimate the risk of future chronicity or remission of stuttering and to find out whether and how it is possible to differentiate normal developmental dysfluencies from chronic abnormal dysfluencies. Preliminary results are presented and discussed.