Switching from oral extended-release methylphenidate to the methylphenidate transdermal system: continued attention-deficit/hyperactivity disorder symptom control and tolerability after abrupt conversion

OBJECTIVE

To evaluate symptom control and tolerability after abrupt conversion from oral extended-release methylphenidate (ER-MPH) to methylphenidate transdermal system (MTS) via a dose-transition schedule in children with attention-deficit/hyperactivity disorder (ADHD).

METHODS

In a 4-week, prospective, multisite, open-label study, 171 children (164 intent-to-treat) with diagnosed ADHD aged 6-12 years abruptly switched from a stable dose of oral ER-MPH to MTS in nominal dosages of 10, 15, 20, and 30 mg using a predefined dose-transition schedule. After the first week on the scheduled dose, the dose was titrated to optimal effect. The primary effectiveness outcome was the change from baseline (while taking ER-MPH) to week 4 in ADHD-Rating Scale-IV (ADHD-RS-IV) total scores. Adverse events (AEs) were assessed throughout the study.

RESULTS

Most subjects (58%) remained on the initial MTS dose defined by the dose-transition schedule; 38% increased and 4% decreased their MTS dose for optimization. MTS dose optimization resulted in significantly better ADHD-RS-IV total (mean +/- SD) scores at week 4 than at baseline (9.9 +/- 7.47 vs. 14.1 +/- 7.48; p < 0.0001). The most commonly reported AEs included headache, decreased appetite, insomnia, and upper abdominal pain. Four subjects (2.3%) discontinued because of application site reactions and three discontinued because of other AEs.

CONCLUSIONS

Abrupt conversion from a stable dose of oral ER-MPH to MTS was accomplished using a predefined dose-transition schedule without loss of symptom control; however, careful titration to optimal dose is recommended. Most AEs were mild to moderate and, with the exception of application site reactions, were similar to AEs typically observed with oral MPH. Limitations of this study included its open-label sequential design without placebo, which could result in spurious attribution of improvement to the study treatment and precluded superiority determinations of MTS over baseline ER-MPH treatment. The apparent superiority of MTS was likely due to more careful titration and clinical monitoring rather than the product itself. ClinicalTrials.gov: NCT00151983.

Summary of the practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults

This practice parameter describes treatment with stimulant medication. It uses an evidence-based medicine approach derived from a detailed literature review and expert consultation. Stimulant medications in clinical use include methylphenidate, dextroamphetamine, mixed salts of amphetamine, and pemoline. They carry U.S. Food and Drug Administration indications for the treatment of attention-deficit hyperactivity disorder.

Summary of the practice parameter for the prevention and management of aggressive behavior in child and adolescent psychiatric institutions with special reference to seclusion and restraint

This parameter reviews the current state of the prevention and management of child and adolescent aggressive behavior in psychiatric institutions, with particular reference to the indications and use of seclusion and restraint. It also presents guidelines that have been developed in response to professional, regulatory, and public concern about the use of restrictive interventions with aggressive patients with regard to personal safety and patient rights. The literature on the use of seclusion, physical restraint, mechanical restraint, and chemical restraint is reviewed, and procedures for carrying out each of these interventions are described. Clinical and regulatory agency perspectives on these interventions are presented. Effectiveness, indications, contraindications, complications, and adverse effects of seclusion and restraint procedures are addressed. Interventions are presented to provide more opportunities to promote patient independence and satisfaction with treatment while diminishing the necessity of using restrictive procedures.

Randomized, controlled trial of oros methylphenidate once a day in children with attention-deficit/hyperactivity disorder

OBJECTIVE

A new once-a-day methylphenidate (MPH) formulation, Concerta (methylphenidate HCl) extended-release tablets (OROS MPH), has been developed. This study was conducted to determine the safety and efficacy of OROS MPH in a multicenter, randomized, clinical trial.

METHODS

Children with attention-deficit/hyperactivity disorder (ADHD; n = 282), all subtypes, ages 6 to 12 years, were randomized to placebo (n = 90), immediate-release methylphenidate (IR MPH) 3 times a day (tid; dosed every 4 hours; n = 97), or OROS MPH once a day (qd; n = 95) in a double-blind, 28-day trial. Outcomes in multiple domains were assessed, and data were analyzed using analysis of variance and Kaplan Meier product limit estimates for time to study cessation. The primary time point for analysis was the last available patient visit using last observation carried forward.

RESULTS

Children in the OROS and IR MPH groups showed significantly greater reductions in core ADHD symptoms than did children on placebo. This was true both at the end of week 1 and at the end of treatment on the basis of mean teacher and parent IOWA Conners ratings. IR MPH tid and OROS MPH qd did not differ significantly on any direct comparisons. Forty-eight percent of the placebo group discontinued early compared with 14% and 16% in the IR MPH and OROS MPH groups, respectively.

CONCLUSIONS

For the treatment of core ADHD symptoms, OROS MPH dosed qd and IR MPH dosed tid were superior to placebo and were not significantly different from each other.attention-deficit/hyperactivity disorder, methylphenidate, OROS, Concerta.

Dose-response effects of methylphenidate on ecologically valid measures of academic performance and classroom behavior in adolescents with ADHD

The effects of methylphenidate on the academic performance and classroom behavior of 45 adolescents with attention deficit hyperactivity disorder were studied. During a 6-week, placebo-controlled medication assessment in the context of a summer treatment program, participants received a double-blind, crossover trial of 3 doses of methylphenidate. Dependent measures included note-taking quality, quiz and worksheet scores, written language usage and productivity, teacher ratings, on-task and disruptive behavior, and homework completion. Group data showed positive effects of methylphenidate on academic measures; however, the greatest benefit came with the lowest dose. Although additional benefit did occur for some participants with higher doses, the largest increment of change usually occurred between the placebo and 10-mg dose. Many adolescents did not experience added benefit with increased dosages, and in some cases they experienced deterioration. Guidelines for assessment of medication effects are discussed.

Behavioral versus behavioral and pharmacological treatment in ADHD children attending a summer treatment program

As part of the behavioral treatment in the Multimodal Treatment Study of Children with ADHD (MTA9), children participated in an intensive summer treatment program (STP). This study examined the differences between 57 children in the combined treatment (Comb) group, who were medicated, and 60 children in the behavioral treatment (Beh) group, who were unmedicated throughout the STP. Comb children were significantly better than Beh on 5 measures: rule following, good sportsmanship, peer negative nominations, and STP teacher posttreatment ratings of inattention/overactivity. Groups did not differ on any of the other 30 measures, and responded similarly to the STP over time. Comparisons to normative data revealed that Comb children were more likely to fall within the normative range on 6 measures. The differences between these results and the main MTA results, in which Comb was always superior to Beh, are discussed in terms of the relative intensity of combined treatments. The implications for future studies of pharmacological and behavioral treatment for ADHD are discussed.

Practice parameters for the assessment and treatment of children and adolescents with substance use disorders. American Academy of Child and Adolescent Psychiatry

These practice parameters describe the assessment and treatment of children and adolescents with substance use disorders and are based on scientific evidence regarding diagnosis and effective treatment as well as on the current state of clinical practice. Given the paucity of research on the treatment of substance use disorders in children and adolescents, many of the recommendations are drawn from the adult literature and current clinical practice. These parameters consider risk factors for substance use and related problems, normative use of substances by adolescents, the comorbidity of substance use disorders with other psychiatric disorders, and treatment settings and modalities.

Clonazepam as an augmenting agent in the treatment of childhood-onset obsessive-compulsive disorder

This case study is of a young man with childhood onset of severe obsessive-compulsive disorder (OCD). The patient had no clinical improvement during therapeutic trials of clomipramine, fluoxetine, and fluvoxamine, including buspirone augmentation. The patient consumed 50 tablets of fluoxetine in a suicide attempt and experienced a total remission of his OCD symptoms for the first time in his life. This remission lasted approximately 1 month and raises interesting questions about the mechanism of action of the serotonin reuptake inhibitors. Subsequently, the patient was able to achieve a 75% improvement in symptomatology when treated with a combination of fluoxetine and clonazepam. This open report suggests that clonazepam may be an effective augmentation agent to a serotonin reuptake inhibitor in the treatment of OCD.

The Teen-Addiction Severity Index: rationale and reliability

There is an urgent need for a reliable method of evaluating the severity of adolescent chemical abuse and problems related to chemical abuse. The lack of an appropriate rating scale to fill this objective hampers the design and the assessment of objective treatment outcome and follow-up of adolescent chemical abusers. The Teen-Addiction Severity Index (T-ASI) is a structured interview which was developed to assess the seven following domains: chemical use, school status, employment-support status, family relationships, peer-social relationships, legal status, and psychiatric status. This paper discusses the rationale for the design of the T-ASI and presents a preliminary study indicating satisfactory interrater reliability of the rating scale.

Multivariate comparison of adolescent offspring of substance abuse parents: community and treatment samples

Adolescent offspring of substance abuse parents (SA+) were compared on the scales of the Drug Use Screening Inventory to offspring of control parents (SA-). Neither clinical nor community samples of SA+ subjects were different from controls. These findings indicate that parental substance abuse does not necessarily impart maladjustment to their offspring.

Drug abuse severity in adolescents is associated with magnitude of deviation in temperament traits

Substance abusing adolescents were discriminated from normal controls on seven of the nine scales comprising the revised Dimensions of Temperament Scales. However, upon aggregating the scales into orthogonal dimensions using factor analysis, it was found that only activity level was associated with drug use severity. This behavioural trait was correlated with seven of 10 scales comprising the Drug Use Screening Inventory, including severity of substance use, behavior problems, psychiatric disorder, work, peer relationships and leisure activities.

Reliability and validity of the structured interview for personality disorders in adolescents

The Structured Interview for the DSM-III Personality Disorders was administered to 23 currently affectively ill adolescents and their parents. Interviews were videotaped and rerated; interrater agreement was moderate (weighted K = 0.49; unweighted K = 0.59). Moreover, there was evidence of convergent validity for Cluster II traits and disorders (borderline, histrionic, narcissistic), insofar as these diagnoses were associated with higher scores on the novelty-seeking subscale of the Tridimensional Personality Questionnaire as predicted. Cluster II patients tended to have higher rates of attention deficit disorder and bipolar disorder, and higher rates of suicidal gestures among second-degree relatives. Some difficulty was encountered differentiating symptoms of affective illness from those of personality disorder and in deciding when personality traits were impairing enough to call them disorders. Reliability may be improved by: (1) interviewing patients when out of affective episode; and (2) using standardized functional impairment criteria for differentiating personality style from disorder. Additional work is advocated to learn if personality disorders are precursors, epiphenomena, or the consequences of affective disorder.

Adolescent chemical use and dependence: current issues in epidemiology, treatment and prevention

This review provides a pragmatic and clinical orientation to current issues in adolescent chemical dependence in addition to exploring legitimate and relevant unanswered questions about chemical dependence. The lack of research on adolescent chemical dependence is addressed in light of the updated epidemiology. Patterns of use, abuse and dependence among adolescents are reviewed. The article examines treatment issues as well as prevention strategies among children and adolescents. Future clinically oriented research directions are suggested to promote further investigation into these areas.