Langzeitwirksames Methylphenidat bei Kindern mit Aufmerksamkeitsdefizit-Hyperaktivitätsstörungen

Zusammenfassung

Langzeitwirksame Methylphenidatpräparate mit einer zweistufigen Freisetzungsdynamik (Stufe 1: rasch; Stufe 2: verzögert) erlauben eine morgendliche Einmalgabe und werden so der Unterstützung von Schulkindern mit ADHS besser gerecht. Das diesbezüglich erste deutsche Arzneimittel (Medikinet® Retard 20 mg) sollte daher auf seine Wirksamkeit und Verträglichkeit geprüft werden.

In einer plazebokontrollierten, randomisiert-parallelen, doppelblinden, multizentrischen Studie wurden 85 normal intelligente Kinder (Alter 6–16 Jahre, Diagnose ADHS) untersucht. Die Dauer der Behandlung mit Medikinet Retard (n = 43) bzw. Plazebo (n = 42) betrug 4 Wochen mit wöchentlichen Visiten und einer wöchentlichen Titrierung. Hauptzielkriterium war die Symptomatik im Fremdbeurteilungsbogen für hyperkinetische Störungen (FBB-HKS durch die Lehrer) im Vergleich der Woche 0 (Anfangswert) gegenüber der Woche 4 (Endwert). Unerwünschte Ereignisse und unerwünschte Arzneimittelwirkungen (UAW) sowie laborchemische und kardiovaskuläre Parameter wurden erfasst und EEG, internistische und neurologische Untersuchung durchgeführt.

Es zeigte sich eine deutlich positive Medikamentenwirkung (U-Test: p <0,001). Die Effektstärke der Veränderungen lag bei d = 1,03. Die Dauer der Wirksamkeit hielt für das langzeitwirksame Methylphenidat meistens den gesamten Schulvormittag an. Die Verträglichkeit von Medikinet Retard wurde von Eltern, Patienten und Ärzten als gut bis sehr gut eingeschätzt.

Damit liegen im deutschsprachigen Raum erstmals Daten für eine erfolgreiche Symptomreduktion und gute Verträglichkeit eines langzeitwirksamen Methylphenidatpräparates (Medikinet Retard) vor. Die zweistufige Freisetzungsdynamik erlaubt eine praxistaugliche morgendliche Einmalgabe.

Long-acting methylphenidate has an effect on aggressive behavior in children with attention-deficit/hyperactivity disorder

INTRODUCTION

Aggression is frequently observed in children and adolescents with attention-deficit/hyperactivity disorder (ADHD). The aim of this study was to assess the efficacy with regard to oppositional and aggressive behavior of a new long-acting methylphenidate preparation (Medikinet retard, MPH-MR), with equal portions of the immediate-release and the sustained-release active substance, and especially to look at correlations between either teacher or parent assessment of aggression and ADHD sub-symptomatology.

METHODS

Eighty five children and adolescents (6-16 years) were investigated in a double-blind, randomized, clinical trial over 5 weeks under a treatment with MPH-MR using symptom checklists for ADHD, oppositional-defiant and conduct disorder according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV).

RESULTS

A total of 64.9% of the children showed oppositional defiant disorder/conduct disorder (ODD/CD) symptoms. A statistically significant effect was found in the group treated with MPH (verum-group). On the basis of Cohen's criteria, high effects were found for aggressive symptoms in school (d = 1.0), but not in the afternoon (d = 0.4). There were also lower effect sizes for more severe aggressive symptoms. We found characteristic correlations between ODD/CD symptoms and the ADHD subscale hyperactivity/impulsivity compared to the subscale inattention.

CONCLUSIONS

Long-acting MPH is effective in the treatment of oppositional-defiant and aggressive behavior, especially concerning milder symptoms. The expected correlation between impulsivity and aggressiveness could be confirmed.

A genome-wide scan for attention-deficit/hyperactivity disorder in 155 German sib-pairs

Three groups have previously performed genome scans in attention-deficit/hyperactivity disorder (ADHD); linkage to chromosome 5p13 was detected in all of the respective studies. In the current study, we performed a whole-genome scan with 102 German families with two or more offspring who currently fulfilled the diagnostic criteria for ADHD. Including subsequent fine mapping on chromosome 5p, a total of 523 markers were genotyped. The highest nonparametric multipoint LOD score of 2.59 (empirical genome-wide significance 0.1) was obtained for chromosome 5p at 17 cM (according to the Marshfield map). Subsequent analyses revealed (a) a higher LOD score of 3.37 at 39 cM for a quantitative severity score based on symptoms of inattention than for hyperactivity/impulsivity (LOD score of 1.11 at 59 cM), and (b) an HLOD of 4.75 (empirical genome-wide significance 0.001) based on a parametric model assuming dominant inheritance. The locus of the solute carrier 6A3 (SLC6A3; dopamine transporter 1; DAT1) localizes to 5p15.33; the gene has repeatedly been implicated in the etiology of ADHD. However, in our sample the DAT1 VNTR did not show association with ADHD. We additionally identified nominal evidence for linkage to chromosomes 6q, 7p, 9q, 11 q, 12q and 17p, which had also been identified in previous scans. Despite differences in ethnicity, ascertainment and phenotyping schemes, linkage results in ADHD appear remarkably consistent.

Transmission disequilibrium of polymorphic variants in the tryptophan hydroxylase-2 gene in attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is the most common behavioral disorder in childhood with substantial heritability. Pharmacological and molecular genetic studies as well as characterization of animal models have implicated serotonergic dysfunction in the pathophysiology of ADHD. Here, we investigated the effect of polymorphic variants in the gene of the tryptophan hydroxylase-2 (TPH2), the rate-limiting enzyme of serotonin (5-HT) synthesis in the brain, in children and adolescents with ADHD. We analyzed three single nucleotide polymorphisms (SNPs) in and downstream of the transcriptional control region of the TPH2 gene in 103 families with 225 affected children. Allelic association in families with more than one affected child was assessed using the pedigree disequilibrium test. Preferential transmissions were detected for the two SNPs in TPH2's regulatory region (rs4570625, P=0.049; rs11178997, P=0.034), but not for the third SNP in intron 2 (rs4565946, P=0.3517). Haplotype analysis revealed a strong trend of association between the regulatory region SNPs (rs4570625, rs11178997) and ADHD (P=0.064). Our results link potentially functional TPH2 variations to the pathophysiology of ADHD, and further support the relevance of 5-HT in disorders related to altered motor activity and cognitive processes.

[Formal genetic findings in attention-deficit/hyperactivity-disorder]

Twin, family and adoption studies have led to a solid understanding of the contribution of both genetic and environmental factors to the development of attention deficit/hyperactivity disorder (ADHD). We review recent studies under consideration of both methodological aspects and relevant findings. Heritability estimates in the range of 0.6 - 0.8 surpass those for most other child and adolescent psychiatric disorders. First degree relatives have elevated rates for ADHD, affective disorders, conduct disorders and substance abuse and dependency. The ADHD subtype of the index patient does not predict the subtype of other family members affected with ADHD; hence non-genetic factors seemingly account for this intrafamilial variability. Because the familial rates for ADHD are not higher in families of female in comparison to male index patients, there is no indication that the genetic loading is higher in affected females. Recently, rater effects have been discussed broadly: Whereas the heritability estimates are uniformly high independent of the informant (mother, father, teacher), the correlations between quantitatively rated symptoms are low between different informants. Knowledge of the formal genetic aspects of ADHD is a prerequisite for understanding the results of recent molecular genetic studies.

[Brief report of the working group OPD-CA (children and adolescents) Axis I: subjective dimensions, resources, and preconditions for treatment]

The progress of work in adaptation axis I of OPD (operationalized psychodynamic diagnostic) to axis I OPD-CA (children and adolescents) is delineated. The items are now classified as subjective dimensions, resources and preconditions for treatment. Overlapping with the multi-axial classification for children and adolescents as used in Germany (MAS) was eliminated and important items for child and adolescent psychiatric and psychotherapeutic treatment were added. In the field of personal dimensions only subjective impairment will be covered. Resources were accentuated for the benefit of peer relationships. Motivation for treatment is now differentiated between a more global motivation for change and motivation for psychotherapeutic treatment. In order to reduce ambiguity the term of compliance was transformed into ability for therapeutic agreement. The possibility of realization of therapeutic indication was added.

[Psychosocial aspects in total external ear reconstruction in patients with severe microtia]

BACKGROUND

The aim of this study was to identify the psychosocial problems and expectation of patients with severe microtia and to investigate possible changes in psychosocial profile of patients after surgical reconstruction of the pinna.

METHODS

Interviews were performed with 65 patients before and 39 patients after auricular reconstruction. They consisted of a questionnaire involving open and closed questions relating to the reconstruction and a personality test.

RESULTS

The most frequently mentioned reasons for surgery were: personal dissatisfaction with patients own appearance, lack of self-confidence, and for younger age groups, parental anxiety about the future psychosocial development of their children. More than 90% of the patients with surgically reconstructed auricles were satisfied with the postoperative results and showed a more open and fearless personality profile.

CONCLUSIONS

Auricular reconstruction enhances the development of a stable personality.

[Professional concept of physicians in child and adolescent psychiatry in former East Germany (1990)]

For this study the authors prepared a questionnaire for 662 child and youth psychiatrists with a return quota of 45%. Careerwise most medical doctors--working as psychiatrists and psychotherapists with an equal distribution in hospitals and offices--acquired further special training and education, particularly in Pediatrics, Psychotherapy and Autogenous Training. Work performance meets general agreement: a noticeable lack of corresponding doctors offices, mainly due to the economic situation. Unequivocal agreement exists concerning the necessity of diagnosis, the necessity of out-patient and in-patient therapy, as well the necessity of interdisciplinary cooperation. The views, however, on the quality of cooperation and the hierarchy within the team show differences. Views on self-concept almost equally determined an identification as doctor and as psychotherapist. The main professional motivations were enjoyment, success and ability. The professional concept was unvocally agreed upon. The survey revealed a poor reputation of child and adolescent psychiatrists. Professional basics include preserving the complexity in the field of child and adolescent psychiatry including medical assignments onesidedness rejected. Conflicts arise concerning the "professional self concept", resulting from the thin line between the required separation of child and adolescent psychiatry and associated professions and the required cooperation with associated professions.

[Stigmatizing patients at an inpatient unit of child and adolescent psychiatry]

In a pilot study covering a sample of n = 25 children formerly treated as in-patients within a child psychiatric unit and n = 40 parents of former in-patients, approx. 30% of the parents indicated that their children had been exposed to stigmatizing behaviour reactions by their social environment in consequence of their stay at the unit. The children themselves felt stigmatized in approx. 50% of cases. Correlations between stigmatization and demographic variables, characteristics of treatment or subjects' attitudes towards child and adolescent psychiatry were rarely found to be significant. Because of their fear of stigmatization, there are tendencies among parents as well as patients to conceal the children's in-patient treatment, these tendencies sometimes even concerning the inner family circle. The paper stresses the need for child and adolescent psychiatry to face the problem of patient stigmatization and suggests possible steps to be taken in order to relieve or even prevent stigmatization.

[Termination of therapy in inpatient treatment]

A retrospective study of terminators against medical advice (11.8% of all treated families) of a clinic of child and adolescence psychiatry tries to evaluate the motives of the drop-outs. The relationships between drop-out families and therapists seemed to be disturbed in 10 cases. 13 of the parents found the relationship between their child and therapist negative. Over all the communication of terminator-families and therapists seemed to be seriously disturbed. It is very important to clarify the setting with the family to prevent a situation in which the resistance of the family increases. The results are described and discussed with relevant studies on this field.

[Possibilities of the rehabilitation of children and adolescents with behavior disorders]

After introducing the definition and classification of behaviour disorders in children and adolescents, the author describes the criteria of diagnosis and the procedures at the beginning of rehabilitation measures. Their legal basis in the Federal Republic of Germany is discussed and the institutional possibilities (child guidance, in- and outpatients, home treatment, day hospital, educational establishments etc.) are described. The author concludes that in spite of improvements achieved, present possibilities of rehabilitation of children and adolescents suffering from behavioural disorders (i.e. psychiatric diseases) are still unsatisfactory.

[EEG frequency analyses in children and adolescents with obsessive-compulsive neuroses]

A controlled clinical study was conducted of 25 girls and boys (mean age: 12;7 years) with obsessive-compulsive disorders and 26 patients (mean age: 13;4 years) with other neurotic disorders. None of the subjects had any organic brain disorders. The question addressed was whether there are any EEG findings specific to the group of patients with obsessive-compulsive disorders, as several authors have reported. The EEG frequency analyses (power spectra) showed abnormal findings (fronto-temporal dysfunction and/or electrobiologically delayed maturation) in two thirds of the subjects with obsessive syndromes. The difference between the two groups was not significant, however. Thus the hypothesis of specific EEG patterns in obsessive-compulsive disorders could not be supported.

[Cerebral attacks in childhood and adolescence. Types, diagnostic and therapeutic possibilities (author's transl)]

General practitioners, pediatricians, welfare and school medical officers are frequently first confronted with cerebral attacks in childhood and adolescence. The diagnostic and therapeutic possibilities have been considerably widened in recent decades, they are more differentiated and more extensive. The prognosis of many attacks is therefore often favorable today. Close cooperation between the practitioner and specially equipped departments (neuropediatric and child psychiatric outpatients and clinics) is, however, indispensable for a successful therapeutic procedure and should be further intensified in the future. The phenomenology and incidence, frequency and age-dependence of childhood attacks are discussed and also the present state of diagnostic and therapeutic perspectives in general and hospital practice.