European guidelines on managing adverse effects of medication for ADHD

The Impact of Methylphenidate on Pubertal Maturation and Bone Age in ADHD Children and Adolescents: Results from the ADHD Drugs Use Chronic Effects (ADDUCE) Project

OBJECTIVE

The short-term safety of methylphenidate (MPH) has been widely demonstrated; however the long-term safety is less clear. The aim of this study was to investigate the safety of MPH in relation to pubertal maturation and to explore the monitoring of bone age.

METHOD

Participants from ADDUCE, a two-year observational longitudinal study with three parallel cohorts (MPH group, no-MPH group, and a non-ADHD control group), were compared with respect to Tanner staging. An Italian subsample of medicated-ADHD was further assessed by the monitoring of bone age.

RESULTS

The medicated and unmedicated ADHD groups did not differ in Tanner stages indicating no higher risk of sexual maturational delay in the MPH-treated patients. The medicated subsample monitored for bone age showed a slight acceleration of the bone maturation after 24 months, however their predicted adult height remained stable.

CONCLUSION

Our results do not suggest safety concerns on long-term treatment with MPH in relation to pubertal maturation and growth.

Effectiveness of applied and casual games for young people's mental health: A systematic review of randomised controlled studies

Many youth experience mental health problems and digital games hold potential as mental health interventions. This systematic review provides an overview of randomised controlled studies assessing the effectiveness of digital applied and casual games for improving mental health in youth aged 6-24 years. A systematic search of PsycINFO, Web of Science and Pubmed yielded 145 eligible studies. Studies on (sub)clinical participant samples (n = 75) most often focused on attention-deficit/hyperactivity disorder (ADHD), autism and anxiety. Applied games were found most effective for improving social skills, verbal memory and anxiety, whereas casual games were found most effective for improving depression, anxiety and ADHD. Studies involving healthy youth (n = 70) were grouped into papers examining anxiety in medical settings, momentary effects on positive and negative affect, and papers employing a longitudinal design measuring mental health trait outcomes. Promising results were found for the use of games as distraction tools in medical settings, and for applied and casual games for improving momentary affect. Overall, our findings demonstrate the potential of digital games for improving mental health. Implications and recommendations for future research are discussed, such as developing evaluation guidelines, clearly defining applied games, harmonising outcome measures, including positive outcomes, and examining nonspecific factors that may influence symptom improvement as well.

Alpha modulation via transcranial alternating current stimulation in adults with attention-deficit hyperactivity disorder

Background

One potential therapy treating attention-deficit/hyperactivity disorder (ADHD) is to modulate dysfunctional brain activations using brain stimulation techniques. While the number of studies investigating the effect of transcranial direct current stimulation on ADHD symptoms continues to increase, transcranial alternating current stimulation (tACS) is poorly examined. Previous studies reported impaired alpha brain oscillation (8-12 Hz) that may be associated with increased attention deficits in ADHD. Our aim was to enhance alpha power in adult ADHD patients via tACS, using different methods to explore potential therapeutic effects.

Methods

Undergoing a crossover design, adults with ADHD received active and sham stimulation on distinct days. Before and after each intervention, mean alpha power, attention performance, subjective symptom ratings, as well as head and gaze movement were examined.

Results

Frequency analyses revealed a significant power increase in the alpha band after both interventions. Despite a trend toward an interaction effect, this alpha power increase was, however, not significantly higher after active stimulation compared to sham stimulation. For the other measures, some additional pre-post effects were found, which were not intervention-related.

Conclusion

Our study cannot provide clear evidence for a tACS-induced increase in alpha power in adult ADHD patients, and thus no stimulation related improvement of attention parameters. We provide further recommendations for the future investigation of tACS as a potential ADHD treatment.

Remote neurocognitive interventions for attention-deficit/hyperactivity disorder - Opportunities and challenges

Improving neurocognitive functions through remote interventions has been a promising approach to developing new treatments for attention-deficit/hyperactivity disorder (AD/HD). Remote neurocognitive interventions may address the shortcomings of the current prevailing pharmacological therapies for AD/HD, e.g., side effects and access barriers. Here we review the current options for remote neurocognitive interventions to reduce AD/HD symptoms, including cognitive training, EEG neurofeedback training, transcranial electrical stimulation, and external cranial nerve stimulation. We begin with an overview of the neurocognitive deficits in AD/HD to identify the targets for developing interventions. The role of neuroplasticity in each intervention is then highlighted due to its essential role in facilitating neuropsychological adaptations. Following this, each intervention type is discussed in terms of the critical details of the intervention protocols, the role of neuroplasticity, and the available evidence. Finally, we offer suggestions for future directions in terms of optimizing the existing intervention protocols and developing novel protocols.

Overcoming defensive responding in the estimation of prevalence of non-medical use of prescription stimulants

BACKGROUND

Prevalence of Non-Medical Use of Prescription Stimulants (NMUPS) is estimated to be high among young adults enrolled in college. However, precise estimation of the prevalence of NMUPS is challenging owing to biases affecting self-report of sensitive and potentially illegal behaviors.

OBJECTIVE

This study aimed to estimate the prevalence and risk factors of NMUPS using the crosswise randomized response technique (CRRT) and compare findings to the traditionally-used direct self-report (DSR) method.

METHODS

This study utilized a cross-sectional, randomized experimental design to survey adult undergraduate students at a major southeastern university in the United States. Eligible respondents were randomly assigned to a DSR group or a CRRT group. Those in the DSR group were presented a direct question about NMUPS, but those in the CRRT group were asked to indicate whether their response to the NMUPS question was the 'same' or 'different' compared to a random non-sensitive question.

RESULTS

Prevalence of NMUPS was found to be 18.6% (95% CI:18.5%-18.7%) in the DSR group and 32.5% (95% CI:32.1%-32.9%; p = 0.003) in the CRRT group. Logistic regression analysis predicting NMUPS in the DSR group showed that it was significantly associated with positive expectancies (OR:3.50; 95% CI:2.44-5.02), negative expectancies (OR:0.49; 95% CI:0.35-0.68), perceived norms (OR:1.71; 95% CI:1.27-2.29), and religious beliefs (OR:0.69; 95% CI:0.52-0.92).

CONCLUSIONS

The setting and mechanism of the survey is likely closely related to the validity of prevalence estimation of sensitive behaviors. This study found that prevalence of sensitive behaviors such as NMUPS is significantly higher when respondents are provided increased anonymity.

Improvement of anxiety in ADHD following goal-focused cognitive remediation: a randomized controlled trial

Introduction

Despite the high prevalence and detrimental consequences of cognitive and executive dysfunction in ADHD, the evidence base of cognitive remediation in the adult ADHD population is sparse. Executive problems can increase both anxiety and depression in ADHD. Thcus, it is important to develop treatment options for adults with ADHD, aiming to improve goal-directed behavior and mood. Goal Management Training (GMT) is an intervention that has received empirical support in improving executive functions and mood in normal aging and for various neurological and psychiatric conditions. The present randomized controlled trial investigated the effects of a goal-focused intervention combining 1) group-based GMT incorporating psychoeducation about ADHD and 2) guidance in implementing individual goals for coping with executive problems in everyday life, compared to treatment as usual (TAU). The primary outcome was perceived executive functioning in everyday life. Secondary outcomes included psychological well-being (anxiety, depression, and coping with ADHD symptoms).

Methods

We recruited 81 adult participants with a verified ADHD diagnosis (Mage   = 31 years). Inclusion was based upon the presence of executive functioning complaints. The participants were randomly assigned to either the intervention or TAU. The intervention group (n = 41) received 16 hours of GMT and psychoeducation, in addition to 4 individual sessions focusing on formulating goals. The goals were assessed in 6 bi-weekly phone calls in the first three months following the group sessions. Participants in the TAU group (n = 40) received standard, individually-adapted follow-up in an outpatient psychiatric health care setting. All participants were assessed at baseline, post-intervention, and at 8-month follow-up (main measurement time point).

Results

Significant improvements in everyday executive functioning, psychological wellbeing, and symptoms of ADHD from baseline to 8-month follow-up were reported in both groups. The intervention group reported a significantly higher reduction in symptoms of anxiety compared to TAU. Conclusions. Our findings provide support for considering cognitive remediation as a treatment option for patients with ADHD.Clinical Trial Registration: https://clinicaltrials.gov/study/NCT04638283?term=NCT04638283&rank=1, identifier: NCT04638283.

Cost-effectiveness and budget impact analysis of lisdexamfetamine versus methylphenidate for patients under 18 with attention-deficit/hyperactivity disorder in Iran

BACKGROUND

Lisdexamfetamine (LDX) and Methylphenidate (MPH) are stimulant agents that have been shown to provide significant benefits in the management of attention-deficit/hyperactivity disorder (ADHD) in patients.

AIM

This study aimed to assess the cost-effectiveness and the budget impact of LDX compared to MPH as the first-line treatment for ADHD.

METHODS

A one-year cost-effectiveness analysis (CEA) was conducted to compare the effects of LDX and MPH in reducing disease symptoms and patient costs and improving quality of life (QoL) from a social perspective. Clinical data were obtained using the EQ-5D questionnaire. In contrast, economic data were sourced from the official website of the Iranian Food and Drug Association (FDA), the national book of tariffs, and specific questionnaires designed to evaluate patients' direct and indirect costs. 197 patients were included in the study, including individuals who sought psychiatric evaluation at a hospital in Mashhad and those who obtained ADHD medications from governmental pharmacies. The cost-effectiveness of the study medicine was assessed using the decision tree method, and the results were presented as the Incremental Cost-Effectiveness Ratio (ICER). Deterministic Sensitivity Analysis (DSA) and Probabilistic Sensitivity Analysis (PSA) were performed to assess the robustness of the findings. Additionally, a Budget Impact Analysis (BIA) was conducted over five years, considering three different scenarios, to evaluate the financial implications of incorporating LDX into the national pharmaceutical system.

RESULTS

The ICER for LDX therapy compared to MPH was estimated at USD 264.28 (with an incremental cost of USD 54.9, incremental effectiveness of 0.208, and Quality-Adjusted Life Years (QALYs) gained of 0.765). The PSA indicated a 0.994% probability of LDX being cost-effective, considering a threshold of USD 2450 per QALY. Furthermore, the DSA revealed that the acquisition cost of LDX influenced the model's sensitivity. The BIA demonstrated that incorporating LDX into Iran's healthcare system would result in a financial burden of approximately $368,566 in the first year, representing an additional cost of $11,154 compared to the non-availability of this medicine and the use of previous medications. It is projected that by 2027, the financial burden of treating ADHD with LDX will reach approximately USD 443,879 over five years, amounting to an increase of $71,154 compared to the absence of this medicine.

CONCLUSION

From a social perspective, the inclusion of LDX in the treatment regimen for ADHD is associated with higher costs and an increased financial burden. However, based on our analysis, LDX appears to be a cost-effective choice for managing ADHD in Iran when compared to MPH.

Self-Reported Adult ADHD Symptoms: Evidence Supporting Cautious Use in an Assessment-Seeking Sample

OBJECTIVE

Self-report symptom inventories are commonly used in adult ADHD assessment, and research indicates they should be interpreted with caution. This study investigated one self-report symptom inventory for adult ADHD in a clinical sample.

METHOD

Archival data were used to evaluate diagnostic utility of the Conners Adult ADHD Rating Scale-Self-Report: Long Version (CAARS-S:L) in a sample of 122 adults seeking ADHD assessment.

RESULTS

Overall, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) estimates for the ADHD Index and other CAARS-S:L scales demonstrated weak accuracy. Anxiety and depression were the most common diagnoses present when a false positive on the ADHD Index was observed. PPV and specificity for the ADHD Index were higher in males compared to females.

CONCLUSION

The CAARS-S:L may be useful for screening purposes in some cases, but should not be the main method used for diagnostic purposes. Clinical implications of findings are discussed.

Athletes With Attention-Deficit/Hyperactivity Disorder: Position Statement of the American Medical Society for Sports Medicine

ABSTRACT

Athletes of all ages may be affected by medical and mental health issues. Sports medicine physicians should be familiar with common conditions that may affect the well-being of athletes, such as attention-deficit/hyperactivity disorder (ADHD). ADHD behaviors have the potential to affect a person's ability to concentrate. It is likely that social and cognitive therapies combined with pharmacotherapy will be the most effective way to treat ADHD in athletes. Medications used for ADHD, especially stimulant types, are known to improve alertness, reaction time, anaerobic performance, and endurance, which would potentially improve athletic performance. Furthermore, stimulant medications may enable student athletes with ADHD to focus on academic studies for longer periods of time, beyond usual levels of fatigue, important for those who may be exhausted after practices and games. The purported performance enhancement effects and potential adverse effects of stimulant medications have prompted many sports governing bodies to ban prescription stimulants or establish strict rules for their use. Athletes taking physician-prescribed stimulants to treat ADHD need to provide the appropriate documentation for approval before competition or risk punitive measures. Physicians should strive to provide a high quality of care to athletes with ADHD through early diagnosis, appropriate and careful multidisciplinary treatment, and complete and timely documentation to facilitate continued sports participation.

Perspectives on heterogeneity-informed cognitive training for attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (AD/HD) is a heterogeneous neurodevelopmental condition, posing a severe threat to quality of life. Pharmacological therapies are the front-line treatment; however, their shortages encourage the development of alternative treatments for AD/HD. One promising method of developing alternative treatments is cognitive training (CT). A CT-based therapy was recently approved by the US Food and Drug Administration. However, due to heterogeneity in AD/HD, a CT protocol is unlikely to provide a one-size-fits-all solution for all patients with AD/HD. Therefore, this article highlights key aspects that need to be considered to further develop CT protocols for AD/HD, regarding training content, timing, suitability, and delivery mode. The perspectives presented here contribute to optimizing CT as an alternative option for treating AD/HD.

Chronic Exercise for Core Symptoms and Executive Functions in ADHD: A Meta-analysis

BACKGROUND AND OBJECTIVES

The effects of chronic exercise interventions (CEIs) on core symptoms and executive functions (EFs) of attention-deficit/hyperactivity disorder (ADHD) and how different characteristics of CEIs could modify the effect remain unclear. We synthesized the current evidence on the effects of CEIs on core symptoms and EFs in children and adolescents with ADHD.

METHODS

Data sources include PubMed, Embase, Web of Science, Cochrane Library, and China National Knowledge Infrastructure from database inception to July 31, 2022. Study selection includes randomized controlled trials that reported on the effects of CEIs on core symptoms and/or EFs in ADHD aged 6 to 18 years.

RESULTS

Twenty-two randomized controlled trials were included. CEIs had a small beneficial effect on overall core symptoms (standardized mean difference [SMD] = -0.39, 95% confidence interval [CI]: -0.64 to -0.14), as well as inattention (SMD = -0.32, 95% CI: -0.63 to -0.004) among children and adolescents with ADHD. Closed-skill exercise showed a large improvement in core symptoms (SMD = -0.83, 95% CI: -1.30 to -0.35), whereas open-skill exercise did not. Additionally, CEIs had a moderately beneficial effect on overall EFs (SMD = -0.68, 95% CI: -0.91 to -0.45) and a moderate-to-large effect on the specific domains of EFs. The pooled effects on overall core symptoms and EFs were not significantly modified by study population (children or adolescents), exercise session duration (≤50 or >50 minutes per session, median), or total exercise sessions (<24 or ≥24 sessions, median).

CONCLUSIONS

CEIs have small-to-moderate beneficial effects on overall core symptoms and EFs in children and adolescents with ADHD.

A literature review of sleep problems and neurodevelopment disorders

INTRODUCTION

Sleep is an incredibly complex process that goes beyond relaxing and body resting. Disturbance in sleep leads to several short-term and long-term consequences. Neurodevelopmental diseases such as "autism spectrum disorder" (ASDs), Attention-deficit hyperactivity disorder (ADHD), and intellectual disability commonly experience sleep disorders that affect their clinical presentation, daily function, and quality of life.

DISCUSSION

The incidence of sleep problems in ASD patients ranges from 32 to 71.5%, especially insomnia, while an estimated 25-50% of people with ADHD report having sleep issues in clinical settings. The incidence of sleep issues is widespread in persons with intellectual disabilities, reaching up to 86%. This article is a literature review covering the neurodevelopmental disorder interaction with sleep disorder and different management.

CONCLUSION

Disorders of sleep are key concerns in children with neurodevelopmental disorders. In this group of patients, sleep disorders are common and tend to be chronic. Recognizing and diagnosis of sleep disorders will enhance their function, response to treatment, and quality of life.

Rearing in an Enriched Environment Ameliorates the ADHD-like Behaviors of Lister Hooded Rats While Suppressing Neuronal Activities in the Medial Prefrontal Cortex

In addition to genetic factors, environmental factors play a role in the pathogenesis of attention deficit/hyperactivity disorder (ADHD). This study used Lister hooded rats (LHRs) as ADHD model animals to evaluate the effects of environmental factors. Male LHR pups were kept in four rearing conditions from postnatal day 23 (4 rats in a standard cage; 12 rats in a large flat cage; and 4 or 12 rats in an enriched environment [EE]) until 9 weeks of age. EE rearing but not rearing in a large flat cage decreased the activity of LHRs in the open field test that was conducted for 7 consecutive days. In the drop test, most rats reared in an EE remained on a disk at a height, whereas most rats reared in a standard cage fell off. RNA sequencing revealed that the immediate-early gene expression in the medial prefrontal cortex of LHRs reared in an EE was reduced. cFos-expressing neurons were reduced in number in LHRs reared in an EE. These results suggest that growing in an EE improves ADHD-like behaviors and that said improvement is due to the suppression of neuronal activity in the mPFC.

Risk of Cardiovascular Diseases Associated With Medications Used in Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-analysis

IMPORTANCE

Use of attention-deficit/hyperactivity disorder (ADHD) medications has increased substantially over the past decades, but there are concerns regarding their cardiovascular safety.

OBJECTIVE

To provide an updated synthesis of evidence on whether ADHD medications are associated with the risk of a broad range of cardiovascular diseases (CVDs).

DATA SOURCES

PubMed, Embase, PsycINFO, and Web of Science up to May 1, 2022.

STUDY SELECTION

Observational studies investigating the association between ADHD medications (including stimulants and nonstimulants) and risk of CVD.

DATA EXTRACTION AND SYNTHESIS

Independent reviewers extracted data and assessed study quality using the Good Research for Comparative Effectiveness (GRACE) checklist. Data were pooled using random-effects models. This study is reported according to the Meta-analyses of Observational Studies in Epidemiology guideline.

MAIN OUTCOMES AND MEASURES

The outcome was any type of cardiovascular event, including hypertension, ischemic heart disease, cerebrovascular disease, heart failure, venous thromboembolism, tachyarrhythmias, and cardiac arrest.

RESULTS

Nineteen studies (with 3 931 532 participants including children, adolescents, and adults; 60.9% male), of which 14 were cohort studies, from 6 countries or regions were included in the meta-analysis. Median follow-up time ranged from 0.25 to 9.5 years (median, 1.5 years). Pooled adjusted relative risk (RR) did not show a statistically significant association between ADHD medication use and any CVD among children and adolescents (RR, 1.18; 95% CI, 0.91-1.53), young or middle-aged adults (RR, 1.04; 95% CI, 0.43-2.48), or older adults (RR, 1.59; 95% CI, 0.62-4.05). No significant associations for stimulants (RR, 1.24; 95% CI, 0.84-1.83) or nonstimulants (RR, 1.22; 95% CI, 0.25-5.97) were observed. For specific cardiovascular outcomes, no statistically significant association was found in relation to cardiac arrest or arrhythmias (RR, 1.60; 95% CI, 0.94-2.72), cerebrovascular diseases (RR, 0.91; 95% CI, 0.72-1.15), or myocardial infarction (RR, 1.06; 95% CI, 0.68-1.65). There was no associations with any CVD in female patients (RR, 1.88; 95% CI, 0.43-8.24) and in those with preexisting CVD (RR, 1.31; 95% CI, 0.80-2.16). Heterogeneity between studies was high and significant except for the analysis on cerebrovascular diseases.

CONCLUSIONS AND RELEVANCE

This meta-analysis suggests no statistically significant association between ADHD medications and the risk of CVD across age groups, although a modest risk increase could not be ruled out, especially for the risk of cardiac arrest or tachyarrhythmias. Further investigation is warranted for the cardiovascular risk in female patients and patients with preexisting CVD as well as long-term risks associated with ADHD medication use.

Diagnostic model optimization method for ADHD based on brain network analysis of resting-state fMRI images and transfer learning neural network

Introduction: Attention deficit and hyperactivity disorder (ADHD) is a common inherited disease of the nervous system whose cause(s) and pathogenesis remain unclear. Currently, the diagnosis of ADHD is mainly based on clinical experience and guidelines that have laid out some diagnostic standards. Our study aimed to apply a learning-based classification method to assist the ADHD diagnosis based on high-dimensional resting-state fMRI. Methods: Our study selected the ADHD-200 Peking dataset of resting-state fMRI, which has an ADHD patient (n = 142) group and a typically developing control (TDC) healthy control (n = 102) group. We first used Pearson and partial correlation coefficients to perform functional connectivity (FC) analysis between ROIs. Then, the Pearson and partial correlation coefficient matrices were concatenated into a dual-channel feature to build a dual data channel as input to the transfer learning neural network (TLNN) architecture. Finally, we transferred the pretrained model from the auxiliary domain to our target domain and fine-tuned it. Results: Based on the Pearson correlation coefficient, FC between ROIs was detected in 22 brain regions, including the fusiform gyrus, superior frontal gyrus, posterior superior temporal sulcus, inferior parietal lobule, anterior cingulate cortex, and parahippocampal gyrus. Based on the partial correlation coefficient, we found FC in the salient network, default network, sensory-motor network, dorsal attention network, and cerebellum network. With the TLNN architecture, we solved the problem of insufficient training data and improved the sensitivity of the classification method. When the VGG model (fine-tuned transfer strategy, 1,024 fully connected layers) was applied, the accuracy of TLNN classification ultimately reached 82%. Conclusion: Our study suggests that completing the training of the target domain by transferring the prior knowledge of the auxiliary domain is effective in solving the classification problem of small sample datasets. Based on prior knowledge of FC analysis, TLNN classification may assist ADHD diagnosis in a new way.

Headache in ADHD as comorbidity and a side effect of medications: a systematic review and meta-analysis

There is mixed evidence on the association between headache and attention-deficit/hyperactivity disorder (ADHD), as well as headache and ADHD medications. This systematic review and meta-analysis investigated the co-occurrence of headache in children with ADHD, and the effects of ADHD medications on headache. Embase, Medline and PsycInfo were searched for population-based and clinical studies comparing the prevalence of headache in ADHD and controls through January 26, 2021. In addition, we updated the search of a previous systematic review and network meta-analysis of double-blind randomized controlled trials (RCTs) on ADHD medications on June 16, 2020. Trials of amphetamines, atomoxetine, bupropion, clonidine, guanfacine, methylphenidate, and modafinil with a placebo arm and reporting data on headache as an adverse event, were included. Thirteen epidemiological studies and 58 clinical trials were eligible for inclusion. In epidemiological studies, a significant association between headache and ADHD was found [odds ratio (OR) = 2.01, 95% confidence interval (CI) = 1.63-2.46], which remained significant when limited to studies reporting ORs adjusted for possible confounders. The pooled prevalence of headaches in children with ADHD was 26.6%. In RCTs, three ADHD medications were associated with increased headache during treatment periods, compared to placebo: atomoxetine (OR = 1.29, 95% CI = 1.06-1.56), guanfacine (OR = 1.43, 95% CI = 1.12-1.82), and methylphenidate (OR = 1.33, 95% CI = 1.09-1.63). The summarized evidence suggests that headache is common in children with ADHD, both as part of the clinical presentation as such and as a side effect of some standard medications. Monitoring and clinical management strategies of headache in ADHD, in general, and during pharmacological treatment are recommended.

Which factors determine clinicians' policy and attitudes towards medication and parent training for children with Attention-Deficit/Hyperactivity Disorder?

Behavioral parent and teacher training and stimulant medication are recommended interventions for children with attention-deficit/hyperactivity disorder (ADHD). However, not all children with ADHD receive this evidence-based care, and the aim of the current study was to find out why. More specifically, we investigated clinicians' policy, guideline use, and attitudes towards medication and parent training when treating children with ADHD, as well as several factors that could affect this. A total of 219 Dutch clinicians (mainly psychologists, psychiatrists and educationalists) completed a survey. Clinicians were likely to recommend medication more often than parent training, and clinicians' policy to recommend medication and parent training was positively associated with their attitudes towards these interventions. Less experienced clinicians and those with a non-medical background reported lower rates of guideline use, whereas clinicians with a medical background reported less positive attitudes towards parent training. Furthermore, a substantial portion of the clinicians based their decision to recommend parent training on their clinical judgement (e.g., prior estimations of efficacy, perceived low abilities/motivation of parents), and many clinicians reported barriers for referral to parent training, such as waiting lists or a lack of skilled staff. To achieve better implementation of evidence-based care for children with ADHD, guidelines should be communicated better towards clinicians. Researchers and policy-makers should further focus on barriers that prevent implementation of parent training, which are suggested by the discrepancy between clinicians' overall positive attitude towards parent training and the relatively low extent to which clinicians actually advise parent training.

Comparing the Transfer Effects of Three Neurocognitive Training Protocols in Children With Attention-Deficit/Hyperactivity Disorder: A Single-Case Experimental Design

The current study used behavioural and electroencephalograph measures to compare the transferability of three home-based interventions — cognitive training (CT), neurofeedback training (NFT), and CT combined with NFT — for reducing symptoms in children with attention-deficit/hyperactivity disorder (AD/HD). Following a multiple-baseline single-case experimental design, twelve children were randomised to a training condition. Each child completed a baseline phase, followed by an intervention phase. The intervention phase consisted of 20 sessions of at-home training. Tau-U analysis and standardised visual analysis were adopted to detect effects. Results showed that CT improved inhibitory function and NFT improved alpha EEG activity and working memory. The combined condition, which was a reduced ‘dose’ of CT and NFT, did not show any improvements. The three conditions did not alleviate AD/HD symptoms. While CT and NFT may have transfer effects on executive functions, considering the lack of improvement in symptoms, this study does not support CT and NFT on their own as a treatment for children with AD/HD.

Clinical trials were missing from regulatory documents of extended-release methylphenidate for ADHD in adults: a case study of public documents

OBJECTIVES

To assess whether drug regulatory agencies decided on applications for extended-release methylphenidate for use in adult ADHD based on select samples of trials.

STUDY DESIGN AND SETTING

Case series of publicly available regulatory documents. We matched an index of extended-release methylphenidate trials for adult ADHD with trials appearing in regulatory documents of extended-release methylphenidate applications. Trials and regulatory documents were identified as part of this systematic review (https://doi.org/10.1002/14651858.CD012857). We sought to identify missing trials in the regulatory documents and to clarify regulatory submission requirements.

RESULTS

We indexed 18 trials and matched those with 13 drug applications (11 approved, 2 rejected) published by 7 agencies. There were trials missing in 7 (54%) of 13 applications, median 4 trials (range 1-6). The median proportion of missing trial participants was 45% (range 23% - 72%). Regulators seemingly require that all trials must be included in new drug applications, but wording is ambiguous.

CONCLUSION

In this sample of extended-release methylphenidate drug applications for adult ADHD, 7 of 13 regulatory decisions were missing entire trials according to public documents, even though regulatory requirements seem to stipulate that all available trials should be included in drug applications.

Drugs for patients with epilepsy and excessive daytime sleepiness

Excessive daytime sleepiness (EDS) and attentional deficits are often observed in people with epilepsy. They may be the consequence of seizures and subclinical discharges as well as of comorbid conditions as obstructive sleep apnea/hypopnea syndrome (OSAS), attention deficit hyperactivity disorder (ADHD), or other less frequent disorders. Excessive daytime sleepiness may also be caused or worsened by antiseizure medications (ASMs). Several meta-analyses suggested that lamotrigine, lacosamide, and perhaps eslicarbazepine are less sedative than other traditional and new ASMs and, in patients prone to somnolence, might be preferred over ASMs with more sedative properties. In patients with severe EDS and/or ADHD, advantages and risks of a treatment with a psychostimulant need to be considered. Methylphenidate, modafinil, armodafinil, pitolisant, and solriamfetol are authorized for use in ADHD and EDS in patients with narcolepsy and some of them also in OSAS. These agents are off-label for the treatment of EDS associated with epilepsy. They do not have proconvulsant effects, although there are several possible risks for patients with epilepsy. The risks of cardiovascular events and psychiatric symptoms should be carefully evaluated as such disorders can coexist with epilepsy and be triggered by these agents. Finally, combination of psychostimulants with ASMs may be associated with several pharmacokinetic drug-drug interactions.

Exploring the Efficacy of a Mindfulness Program for Boys With Attention-Deficit Hyperactivity Disorder and Oppositional Defiant Disorder

Objective: This study was the first attempt to explore the efficacy of a mindfulness protocol for children with attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), and their parents. Method: Fifty male children with ADHD and ODD diagnosis, aged 8 to 12, were randomly assigned to the mindfulness intervention (n = 25) or the wait-list (n = 25) group. Outcome measures included children, parents', and teachers' reports and objective measures of attention. Results: Children from the intervention group had a greater reduction in hyperactive behaviors in the school context (effect size [ES] = 0.59) and a greater improvement in visual sustained attention (ES = 0.77) and in Avoidance and Fusion Questionnaire scores (ES = 0.43) than those in the wait-list control group. No significant effect of the intervention on aggressive behaviors was revealed. Conclusion: A mindfulness intervention for children and their parents showed partial beneficial effects in children with ADHD + ODD.

A self-guided Internet-delivered intervention for adults with ADHD: A feasibility study

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is a prevalent neurodevelopmental disorder that tends to persist into adulthood. Many adults with ADHD seek non-pharmacological treatment in addition to pharmacological treatment. Still, there are few non-pharmacological treatment options available. The aim of the current study was to explore the feasibility of a self-guided Internet-delivered intervention for adults with ADHD.

METHODS

The study has an uncontrolled, within-group, pre-post design. Thirteen participants with an ADHD diagnosis were included and given access to the first three modules of a seven-module intervention. To explore the feasibility of the intervention, the adherence, credibility, and treatment satisfaction were examined. Preliminary efficacy of the intervention was examined through self-report measures of inattention, hyperactivity, depression, anxiety, stress, and quality of life.

RESULTS

In terms of adherence, seven participants (54%) completed all three intervention modules (M = 1.85, SD = 1.3). The participants reported both good credibility and treatment satisfaction with the intervention. The participants also reported challenges related to usability and technical issues. Although the clinical outcomes must be interpreted with caution due to the study design and the small sample size, a statistically significant reduction in severity of inattention was reported by the participants following the intervention (p = .006, d = 1.57). The reduction was non-significant for hyperactivity (p = .326, d = 0.33). The participants who completed all three modules in the intervention (n = 7) also reported a significant decrease in stress (p = .042, d = 0.67) and a significant increase in quality of life (p = .016, d = 0.99). No significant changes were found on measures of anxiety and depression.

CONCLUSION

The adherence to the intervention was relatively low, but the participants who completed the study reported good credibility and satisfaction with the intervention. These results indicate that there is a need to improve the intervention to make it more engaging before conducting a randomized-controlled trial investigating the clinical effects of the full seven-module intervention.

Sleep disorders in attention-deficit hyperactivity disorder and autism spectrum disorder: a pragmatic approach to assessment and management

Sleep is essential for survival and humans spend approximately one-third of their life asleep. Adequate sleep is needed to maintain both physical and psychological health. Routinely getting less than the recommended amount of sleep for your age can have profound negative effects on health, such as increasing the likeliness of psychiatric illness, diabetes, cardiovascular disease and stroke. In children and adults with neurodevelopmental disorders, the prevalence of sleep disorders is significantly higher than in the general population. Given the relationship between sleep and psychiatric disorders, it is essential that psychiatrists have knowledge of the principles of sleep medicine. In this article, we focus on the common sleep disorders found in those with attention-deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) and give an overview of screening, diagnosis and management.

The World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder

BACKGROUND

Misconceptions about ADHD stigmatize affected people, reduce credibility of providers, and prevent/delay treatment. To challenge misconceptions, we curated findings with strong evidence base.

METHODS

We reviewed studies with more than 2000 participants or meta-analyses from five or more studies or 2000 or more participants. We excluded meta-analyses that did not assess publication bias, except for meta-analyses of prevalence. For network meta-analyses we required comparison adjusted funnel plots. We excluded treatment studies with waiting-list or treatment as usual controls. From this literature, we extracted evidence-based assertions about the disorder.

RESULTS

We generated 208 empirically supported statements about ADHD. The status of the included statements as empirically supported is approved by 80 authors from 27 countries and 6 continents. The contents of the manuscript are endorsed by 366 people who have read this document and agree with its contents.

CONCLUSIONS

Many findings in ADHD are supported by meta-analysis. These allow for firm statements about the nature, course, outcome causes, and treatments for disorders that are useful for reducing misconceptions and stigma.

Does Methylphenidate Work in Children and Adolescents with Attention Deficit Hyperactivity Disorder?

OBJECTIVE

Attention deficit hyperactivity disorder (ADHD) is a common psychiatric disorder diagnosed in increasing proportions of children and adolescents. The psychostimulant methylphenidate has been considered the first-line pharmacological treatment for children and adolescents with ADHD for more than 60 years. Considering recent publications on methylphenidate for ADHD, we here give an overview of its effects in children and adolescents with ADHD, elicited by a well-disputed Cochrane review and narratively synthesise the evidence in the field.

METHOD

We searched for systematic reviews and meta-analyses that investigated methylphenidate as an intervention for children and adolescence with ADHD compared with placebo or no treatment. We assessed the quality of the evidence using AMSTAR II.

RESULTS

We found 24 eligible systematic reviews and meta-analyses of which 11 were rated as high- quality evidence according to AMSTAR II. The evidence claiming that methylphenidate is beneficial in treating children and adolescents with ADHD was of very low certainty. The underreporting of adverse events in randomised clinical trials may impede an adequate depiction of the balance between benefits and harms.

CONCLUSIONS

It appears that there is uncertain evidence on group-level to support the claim that methylphenidate is beneficial in treating children and adolescents with ADHD. Future randomised clinical trials and systematic reviews should include individual participant data, which would allow us to assess intervention effects across modifiers, like age, sex, ADHD subtypes, comorbidities, and dose.

Methylphenidate and atomoxetine treatment negatively affect physical growth indexes of school-age children and adolescents with attention-deficit/hyperactivity disorder

AIM

To determine the effects of drug therapy on the physical growth of school-age children and adolescents with attention-deficit/hyperactivity disorder (ADHD).

METHOD

The medical records of 86 participants (average age: 8.9 ± 2.2 years) with ADHD prescribed methylphenidate (MPH) or atomoxetine (ATX) for ≥24 weeks from the Children's Hospital of Chongqing Medical University were analysed.

RESULTS

The Z-scores of height, weight and body mass index (BMI) of children with ADHD decreased significantly over the first six months of MPH treatment (P < 0.001). The slopes of the fitting lines after the first six months of MPH (-0.18, -0.58 and -0.69, respectively) returned over the entire treatment (the slopes changed to -0.027, -0.26 and -0.20, respectively). For ATX, the Z-scores of height of children decreased significantly over the first six months (P < 0.001), but the Z-scores of weight and BMI did not (P > 0.05). The slopes of the fitting lines after the first six months of ATX (-0.058, -0.032 and 0.0094, respectively) changed over the entire treatment (slopes were 0.16, 0.52 and 0.26, respectively). Children taking MPH were more likely to report decreased appetite (P < 0.05). The weight and BMI of the children receiving MPH were significantly correlated with decreased appetite (P < 0.01).

CONCLUSION

The physical growth indexes (PGIs) of school-age children and adolescents with ADHD were negatively affected while taking MPH, and these effects were gradually mitigated with continued treatment. ATX hardly had negative effects on weight and BMI. Neither MPH nor ATX had a significant negative effect on the height of children in long-term ADHD treatment. It is necessary for clinicians to consider children's diet during treatment.

SKILLS - A psychoeducational group programme for children with ADHD

Psychoeducation is regarded as a first line of intervention for attention-deficit/hyperactivity disorder (ADHD). Previous studies have been limited to psychoeducation for adult patients or parents of children with ADHD. Therefore, the aim of the present study was to investigate the acceptability and effectiveness of a psychoeducational group intervention for children with ADHD. The two-session psychoeducational intervention, SKILLS, was completed by 125 children (6-12 years) with ADHD and their parents. Self-ratings and parental ratings of ADHD symptoms, functional impairment and attitudes to diagnosis and treatment were collected before and after treatment. Post-treatment client satisfaction and parental responses to an open question about SKILLS were assessed. The data were analyzed using a combination of quantitative and qualitative (content analysis) methods. A majority of the participants expressed satisfaction with the group intervention. The intervention had no effect on symptoms and level of function, although the parents were more positive to their child's diagnosis after the intervention. The parents were positive to the group format and to the opportunity for their children to meet other children with similar symptoms. Parents wished for more interactive elements and more opportunities for children to share experiences. We concluded that the group intervention was accepted by most participants, although more activating exercises and opportunities for interaction between participants should be included. Since the intervention group was not compared with a control group, the results should be interpreted with caution. Future studies should use a randomized control treatment design and investigate the effect on adherence to later treatment.

The efficacy of real-time functional magnetic resonance imaging neurofeedback for psychiatric illness: A meta-analysis of brain and behavioral outcomes

Real-time functional magnetic resonance imaging neurofeedback (rtfMRI-NF) has gained popularity as an experimental treatment for a variety of psychiatric illnesses. However, there has yet to be a quantitative review regarding its efficacy. Here, we present the first meta-analysis of rtfMRI-NF for psychiatric disorders, evaluating its impact on brain and behavioral outcomes. Our literature review identified 17 studies and 105 effect sizes across brain and behavioral outcomes. We find that rtfMRI-NF produces a medium-sized effect on neural activity during training (g = .59, 95 % CI [.44, .75], p < .0001), a large-sized effect after training when no neurofeedback is provided (g = .84, 95 % CI [.37, 1.31], p = .005), and small-sized effects for behavioral outcomes (symptoms g = .37, 95 % CI [.16, .58], p = .002; cognition g = .23, 95 % CI [-.33, .78], p = .288). Mixed-effects analyses revealed few moderators. Together, these data suggest a positive impact of rtfMRI-NF on brain and behavioral outcomes, although more research is needed to determine how rtfMRI-NF works, for whom, and under what circumstances.

Guideline adherence in German routine care of children and adolescents with ADHD: an observational study

Although guidelines for the assessment and treatment of mental disorders in childhood and adolescence have been available in Germany for several years, there are barely any data on adherence to guidelines in national routine care. Therefore, the study aimed at a nationwide evaluation of guideline adherence (GA) for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder (ADHD) in German routine care in various groups of health care providers (HCPs). Besides a detailed description of GA, the study focused on examining possible differences between professional groups. Furthermore, data based on global self-reports of clinicians were compared with ratings of documented care in individual patients. Protocols of 73 clinicians regarding their handling of ADHD in routine care for 167 patients were rated according to German guideline recommendations for ADHD care. GA was measured as the proportion of components fulfilled in each individual patient as documented by the HCP. The results were compared to a preceding interview with clinicians regarding their GA. Multilevel models were constructed to detect differences in GA between professional groups. Based on mandatory guideline components, adherence rates of 38.9-72.7% were found and classified as moderate (33.3% < GA ≤ 66.6%) to high (GA > 66.6%). The comparison of the GA between the professional groups generally yielded only small differences. Correlations between GA reported globally by the HCPs and GA documented and rated for individual cases were low. Overall, most rates of GA for ADHD in German routine care lay within a moderate range. Targets for enhancement of GA may be the involvement of teachers and schools in the treatment process, the implementation of psychoeducational methods in general, as well as a careful examination of patients, including monitoring of treatment effects during titration trials. The development of further strategies to monitor the quality of ADHD routine care is needed.

[Adherence to guidelines in the diagnosis and treatment of ADHD in children and adolescents in routine care: A representative survey]

Adherence to guidelines in the diagnosis and treatment of ADHD in children and adolescents in routine care: A representative survey Abstract. Objective: The study evaluated guideline adherence in the current routine care of children and adolescents with Attention Deficit-/Hyperactivity Disorder (ADHD) in various groups of healthcare providers nationwide. Method: N = 275 providers from all relevant groups of a Germany-wide random sample (specialists in pediatric and adolescent medicine, child and adolescent psychiatry and psychotherapy, child and adolescent psychotherapists and all Social Pediatric Centers, outpatient departments of child and adolescent psychiatric clinics and behavioral therapy training institutes) participated in an online interview. Results: The recommendations in the guidelines were implemented on average in 75-100 % of the patients. Exceptions were those of teacher/educator exploration and school interventions. Questionnaires on diagnostics and follow-up or psychotherapeutic interventions were applied comparatively rarely, in about 50 % of the patients. Differences between provider groups and correlations with sociodemographic variables were analyzed at the level of the adherence indices. Conclusions: Overall, the participants reported high guideline adherence. We found a high similarity of the data in different care segments within the care providers. Differences in self-reports of the various care groups stimulate considerations of the roles in the care process with ADHD patients.

Tai Chi training for attention deficit hyperactivity disorder: A feasibility trial in college students

OBJECTIVE

Many young adults are affected by attention deficit hyperactivity disorder (ADHD) and often desire non-pharmacological treatment options. Mind-body techniques might serve as complementary therapies to first-line stimulant medications, but studies are limited. Tai Chi is an increasingly popular practice that integrates movement with cognitive skills relevant to ADHD. We performed a feasibility trial of Tai Chi training in undergraduates to inform the design of a fully powered randomized controlled trial (RCT).

METHOD

Undergraduates with ADHD were recruited, screened, enrolled, and assessed at baseline. They were assigned to three parallel seven-week intervention arms, Tai Chi, Active Control (cardio-aerobic fitness), and Inactive Control (no contact), with follow-up assessments. Feasibility of a larger clinical trial was evaluated, especially with respect to enrollment and retention. Additionally, potential clinical outcome measures were examined for practicality and reliability.

RESULTS

21 participants were assessed at baseline and 19 at follow-up (90 % retention). The primary clinical outcome measure, self-reported inattention symptoms (Conners' CAARS-S:L DSM-IV Inattentive Symptoms subscale), exhibited good test-retest reliability in controls (r = 0.87, n = 10) and correlated with reduced mindfulness (FFMQ acting with awareness subscale) at baseline (r = -0.74, n = 20). Class attendance and self-reported daily practice time were variable. Randomization to group classes was hindered by the college students' restricted schedules.

CONCLUSION

The high retention rate and good data quality suggest that an RCT of Tai Chi for ADHD is feasible. Further measures are identified to improve enrollment rates, adherence, and randomization procedures. Future work might extend to other young adult populations and high school students.

Long term methylphenidate exposure and growth in children and adolescents with ADHD. A systematic review and meta-analysis

BACKGROUND

Methylphenidate (MPH) is an efficacious treatment for ADHD but concerns have been raised about potential adverse effects of extended treatment on growth.

OBJECTIVES

To systematically review the literature, up to December 2018, conducting a meta-analysis of association of long-term (> six months) MPH exposure with height, weight and timing of puberty.

RESULTS

Eighteen studies (ADHD n = 4868) were included in the meta-analysis. MPH was associated with consistent statistically significant pre-post difference for both height (SMD = 0.27, 95% CI 0.16-0.38, p < 0.0001) and weight (SMD = 0.33, 95% CI 0.22-0.44, p < 0.0001) Z scores, with prominent impact on weight during the first 12 months and on height within the first 24-30 months. No significant effects of dose, formulation, age and drug-naïve condition as clinical moderators were found. Data on timing of puberty are currently limited.

CONCLUSIONS

Long-term treatment with MPH can result in reduction in height and weight. However, effect sizes are small with possible minimal clinical impact. Long-term prospective studies may help to clarify the underlying biological drivers and specific mediators and moderators.

The female side of pharmacotherapy for ADHD-A systematic literature review

OBJECTIVE

This comprehensive review examined sex differences in prescription rates and efficacy or effectiveness of pharmacotherapy treatment in girls and women with attention deficit hyperactivity disorder (ADHD), while identifying gaps in the scientific knowledge on this topic.

METHOD

A rigorous electronic database search was carried out in order to identify all published studies on female-specific effects of stimulants and non-stimulants in the treatment of ADHD. In total, 2672 studies were screened of which 21 studies (seven on prescription rates, 14 on effects of pharmacotherapy) met the inclusion criteria and were included for analysis.

RESULTS

In all seven studies on ADHD prescription rates, girls received significantly less prescriptions than boys, a difference however no longer seen in adults with the exception of one study. Each of the 14 studies on effectiveness / efficacy found at least one sex-difference in the effects of ADHD pharmacotherapy.

CONCLUSION

Several sex-differences are demonstrated in the prescription, usage and efficacy /effectiveness of both stimulant and non-stimulant ADHD pharmacotherapy. A single daily use of MPH may possibly not be optimal for girls with ADHD and ATX may be a promising medication for girls and women with ADHD. The robustness of this result requires further investigation.

Neurofunctional and behavioural measures associated with fMRI-neurofeedback learning in adolescents with Attention-Deficit/Hyperactivity Disorder

Functional Magnetic Resonance Imaging Neurofeedback (fMRI-NF) targeting brain areas/networks shown to be dysfunctional by previous fMRI research is a promising novel neurotherapy for ADHD. Our pioneering study in 31 adolescents with ADHD showed that fMRI-NF of the right inferior frontal cortex (rIFC) and of the left parahippocampal gyrus (lPHG) was associated with clinical improvements. Previous studies using electro-encephalography-NF have shown, however, that not all ADHD patients learn to self-regulate, and the predictors of fMRI-NF self-regulation learning are not presently known. The aim of the current study was therefore to elucidate the potential predictors of fMRI-NF learning by investigating the relationship between fMRI-NF learning and baseline inhibitory brain function during an fMRI stop task, along with clinical and cognitive measures. fMRI-NF learning capacity was calculated for each participant by correlating the number of completed fMRI-NF runs with brain activation in their respective target regions from each run (rIFC or lPHG); higher correlation values were taken as a marker of better (linear) fMRI-NF learning. Linear correlations were then conducted between baseline measures and the participants' capacity for fMRI-NF learning. Better fMRI-NF learning was related to increased activation in left inferior fronto-striatal regions during the fMRI stop task. Poorer self-regulation during fMRI-NF training was associated with enhanced activation in posterior temporo-occipital and cerebellar regions. Cognitive and clinical measures were not associated with general fMRI-NF learning across all participants. A categorical analysis showed that 48% of adolescents with ADHD successfully learned fMRI-NF and this was also not associated with any baseline clinical or cognitive measures except that faster processing speed during inhibition and attention tasks predicted learning. Taken together, the findings suggest that imaging data are more predictive of fMRI-NF self-regulation skills in ADHD than behavioural data. Stronger baseline activation in fronto-striatal cognitive control regions predicts better fMRI-NF learning in ADHD.

The Effects of Methylphenidate Treatment on Child Growth in Thai Children and Adolescents with Attention-Deficit/Hyperactivity Disorder

Objectives: To determine the effects of methylphenidate treatment on child growth in Thai pediatric patients with attention-deficit/hyperactivity disorder (ADHD). Methods: The medical records of children and adolescents with ADHD, between 5 and 18 years of age, who received pharmacological treatment with methylphenidate as a sole psychiatric medication for ≥1 year between 2001 and 2018 at the Rajanagarindra Institute of Child Development, Thailand, were retrospectively reviewed. Data on anthropometric parameters and methylphenidate use were extracted. Height and weight were converted to age- and gender-corrected standard scores (z-scores) using norms from the Thai pediatric population. Changes in height and weight z-scores were assessed using a paired t-test or one-way repeated measures ANOVA with the Bonferroni correction. Results: In this retrospective observational study, 911 children and adolescents were eligible, with the mean age of 95.0 ± 19.5 months at baseline, the cumulative duration of methylphenidate treatment of 39.4 ± 23.5 months, and the average daily dosage of 14.1 ± 6.2 mg/day. Comparative analysis found no statistically significant change in height z-scores between baseline and last recorded measurement (mean difference = 0.0017, confidence interval [95% CI] = -0.0004 to 0.0038, p = 0.107), while a slight, but significant increase in weight z-scores was observed (mean difference = 0.0271, 95% CI = 0.0179-0.0362, p < 0.001). Longitudinal analysis observed that weight z-scores were significantly decreased during the first year of therapy, but regained in the second year and continued to increase in subsequent years of therapy. Conclusion: Treatment with methylphenidate in our cohort of Thai pediatric patients with ADHD was not associated with growth deficits, except for a slightly significant decrease in weight during the first year of therapy.

Neuroethical issues in cognitive enhancement: Modafinil as the example of a workplace drug?

The use of cognitive-enhancing drugs by healthy individuals has been a feature for much of recorded history. Cocaine and amphetamine are modern cases of drugs initially enthusiastically acclaimed for enhancing cognition and mood. Today, an increasing number of healthy people are reported to use cognitive-enhancing drugs, as well as other interventions, such as non-invasive brain stimulation, to maintain or improve work performance. Cognitive-enhancing drugs, such as methylphenidate and modafinil, which were developed as treatments, are increasingly being used by healthy people. Modafinil not only affects ‘cold’ cognition, but also improves ‘hot’ cognition, such as emotion recognition and task-related motivation. The lifestyle use of ‘smart drugs’ raises both safety concerns as well as ethical issues, including coercion and increasing disparity in society. As a society, we need to consider which forms of cognitive enhancement (e.g. pharmacological, exercise, lifelong learning) are acceptable and for which groups under what conditions and by what methods we would wish to improve and flourish.

A Randomized Controlled Trial Evaluating the Efficacy of a Psychoeducation Program for Families of Children and Adolescents With ADHD in the United Kingdom: Results After a 6-Month Follow-Up

Objective: Psychoeducation forms part of the current practice for ADHD; however, its efficacy is yet to be established. Method: Sixty-nine children/adolescents with ADHD were randomly assigned for their families to receive either a well-structured psychoeducation program (n = 35), or belong to a control group (treatment-as-usual, n = 34). Results: One-way analyses of variance showed a statistically significant Treatment × Time interaction, for ADHD total symptoms, inattention/cognition, and hyperactivity/impulsivity subdomains according to the parents, the first two with medium-large effect sizes. The effects of the intervention on the ADHD total and the inattention/cognition domain persisted after 6 months follow-up. No significant differences in teacher ratings were found; however, an improvement in clinical functioning as measured by clinicians was observed. Conclusion: This psychoeducation program has shown effectiveness in reducing ADHD symptoms when compared with treatment as usual. Psychoeducation needs to be considered as a valid and additional approach in ADHD.

Exploring factors influencing initiation, implementation and discontinuation of medications in adults with ADHD

Background

Adherence to ADHD medication is a complex phenomenon as the decision to adhere is influenced by a range of factors. To design tailored interventions to promote adherence, it is important to understand the factors that influence adherence in the context of its three phases: initiation, implementation and discontinuation.

Objective

The objective of this study was to explore the phase‐specific factors that influence adherence to medication in adults who have a diagnosis of ADHD.

Methods

Three focus groups (FGs) were conducted with twenty adults with ADHD in different metropolitan areas of Sydney, Australia. FGs were transcribed verbatim and thematically analysed.

Results

Participants’ decision to initiate medication (the initiation phase) was influenced by their perceived needs (desire to improve academic and social functioning) and concerns (fear of side‐effects) about medication following a similar process as defined by the Necessity‐Concerns Framework (NCF). The balance between benefits of medication (needs) and side‐effects (concerns) continued to determine participants’ daily medication‐taking (the implementation phase) and persistence (or discontinuation) with their medication. Forgetfulness and stigma were reported as concerns negatively impacting the implementation phase, while medication cost and dependence influenced the discontinuation phase of adherence.

Conclusions

Adults’ decision to initiate, continue or discontinue medication is influenced by a range of factors; some are unique to each phase while some are common across the phases. Participants balanced the needs for the medication against their concerns in determining whether to adhere to medication at each phase. It appears that the NCF has applicability when decision making about medication is explored at the three phases of adherence.

[Recommendations of the Spanish Society of Paediatric Cardiology and Congenital Heart Disease as regards the use of drugs in attention deficit hyperactivity disorder in children and adolescents with a known heart disease, as well as in the general paediatric population: Position statement by the Spanish Paediatric Association]

INTRODUCTION

Approved drugs for attention deficit hyperactivity disorder (ADHD) in Spain are methylphenidate, lisdexamphetamine, atomoxetine and guanfacine. Due to adverse cardiovascular effects, mainly increased blood pressure and heart rate, its use in patients with known or undiagnosed heart disease may be controversial.

OBJECTIVE

To obtain a consensus document from the Spanish Society of Paediatric Cardiology and Congenital Heart Diseases (SECPCC) and experts from other Agencies and Societies as a guide for the paediatric cardiologist and physicians who treat children and adolescents with ADHD.

METHODOLOGY

An analysis was performed on the bibliography and Clinical Practice Guidelines, technical data sheets approved by the Spanish Agency of Medicines and Health Devices, and the Spanish Ministry of Health Guidelines. A Working Group was formed, with a Coordinator, as well as members of the Clinical Cardiology Working Group and Arrhythmia Group of the SECPCC. This Group produced a preliminary document that was reviewed by a group of external experts and a group of internal experts of the SECPCC with a consensus being reached on the final document.

RESULTS

The recommendations of the SECPCC and the group of experts are presented on cardiovascular evaluation prior to treatment in children and adolescents with no known cardiovascular disease and with known cardiovascular disease. The recommendations of the SECPCC and the group of experts are also presented on the use of medications for ADHD in children and adolescents with cardiological symptoms with no evidence of heart disease, congenital heart disease, cardiomyopathy, Marfan syndrome and other aortic diseases, hypertension, and arrhythmias.

Health Care Trajectories for Children With ADHD in France: Results From the QUEST Survey

Objective: The objective of this study is to retrospectively describe the pathway toward ADHD diagnosis and treatment, and identify potential areas for improvement. Method: Parent-reported questionnaires were collected by a national sample of ADHD specialists. Results: In total, 473 complete questionnaires were analyzed. Initial onset of ADHD symptoms was reported at a mean age of 4.45 years. Mean age at diagnosis was 8.07 years, and half of the families had seen at least three health care professionals previously. Psychiatrists were most commonly consulted. A "combined" (89% boys) and inattentive (49% boys) profile was identified. Diagnosis was made 1 year later for the latter group. Two thirds of patients received pharmacological treatment. The delay in diagnosis was identified as the main source of concern for caregivers. Conclusion: The 4-year delay in diagnosis may represent a loss of opportunity. Training health care professionals in the core symptoms of ADHD may help reduce disparities and improve patient trajectory.

Prescription Benzodiazepine Use in Privately Insured U.S. Children and Adolescents

INTRODUCTION

Benzodiazepines are commonly prescribed in the U.S. but entail safety concerns, including dependency. In pediatrics, many indications lack trial data. Authors aimed to describe youth initiating prescription benzodiazepine treatment, identify potential indications and prescribing concerns, estimate the duration of treatment by potential indication, and identify factors that predict long-term use.

METHODS

The study cohort included children (aged 3-12 years) and adolescents (aged 13-17 years) initiating prescription benzodiazepine treatment (≥3 days' supply) from January 2010 to September 2015 in a U.S. commercial claims database. Potential indications included selected ICD-9-CM diagnoses (≤30 days prior). Long-term (≥6 months) benzodiazepine treatment was estimated with Kaplan-Meier estimation and modified Poisson regression identified independent predictors of long-term benzodiazepine treatment (analysis completed in 2018).

RESULTS

Of 24,504 children and 61,046 adolescents initiating benzodiazepines, 62% of the children and 68% of the adolescents had a potential indication. Anxiety disorders were the most common indication, with mental health indications more common among adolescents (45%) than children (23%) and epilepsy and movement disorders higher in children. Recent opioid prescriptions were common before benzodiazepine initiation (children, 22%; adolescents, 21%). Six percent of the initiators became long-term benzodiazepine users. Potential indication, provider contact, psychotropic medication, and chronic conditions independently predicted long-term benzodiazepine treatment in adolescents and children.

CONCLUSIONS

U.S. children and adolescents are prescribed benzodiazepines for various mental health and other medical conditions, many lacking evidence of pediatric efficacy. Long-term benzodiazepine treatment, concurrent opioid prescriptions, psychotropic use, and prior substance use disorder diagnoses suggest safety risks among some youth prescribed benzodiazepines.

Diagnostic Accuracy of the Conners' Adult ADHD Rating Scale in a Postsecondary Population

Objective: Clinicians frequently rely upon the results of self-report rating scales when making the diagnosis of ADHD; however, little research exists regarding the ability of self-report measures to accurately differentiate ADHD from other disorders. Method: This present study investigated the ability of the Conners' Adult ADHD Rating Scale (CAARS) to discriminate between 249 postsecondary students with carefully diagnosed ADHD and 507 clinical controls. Results: The overall discriminant validity of the CAARS was 69%, and it had an unacceptably high false positive and false negative rate. At lower prevalence rates, a high score on the CAARS has only a 22% chance of accurately identifying individuals with ADHD. Conclusion: Although the CAARS is an adequate screening measure, it should not be the main method by which a diagnosis is made, as it frequently misidentifies individuals with other psychological complaints as having ADHD. Implications for clinical practice are discussed.

Risks and Benefits of Attention-Deficit/Hyperactivity Disorder Medication on Behavioral and Neuropsychiatric Outcomes: A Qualitative Review of Pharmacoepidemiology Studies Using Linked Prescription Databases

Attention-deficit/hyperactivity disorder (ADHD) medication is one of the most commonly prescribed medication classes in child and adolescent psychiatry, and its use is increasing rapidly in adult psychiatry. However, major questions and concerns remain regarding the benefits and risks of ADHD medication, especially in real-world settings. We conducted a qualitative systematic review of studies that investigated the effects of ADHD medication on behavioral and neuropsychiatric outcomes using linked prescription databases from the last 10 years and identified 40 studies from Europe, North America, and Asia. Among them, 18 used within-individual designs to account for confounding by indication. These studies suggested short-term beneficial effects of ADHD medication on several behavioral or neuropsychiatric outcomes (i.e., injuries, motor vehicle accidents, education, substance use disorder), with estimates suggesting relative risk reduction of 9% to 58% for these outcomes. The within-individual studies found no evidence of increased risks for suicidality and seizures. Replication studies are needed for several other important outcomes (i.e., criminality, depression, mania, psychosis). The available evidence from pharmacoepidemiology studies on long-term effects of ADHD medication was less clear. We discuss time-varying confounding and other limitations that should be considered when interpreting results from pharmacoepidemiology studies. Furthermore, we highlight several knowledge gaps to be addressed in future research and implications for research on mechanisms of outcomes of ADHD medications.

Influence of Methylphenidate on Long-Term Neuropsychological and Everyday Executive Functioning After Traumatic Brain Injury in Children with Secondary Attention Problems

OBJECTIVE

To investigate the effects of methylphenidate on long-term executive and neuropsychological functioning in children with attention problems following TBI, as well as the relationship between methylphenidate associated changes in lab-based neuropsychological measures of attentional control, processing speed, and executive functioning and parent- or self-report measures of everyday executive functioning.

METHOD

26 children aged 6-17 years, who were hospitalized for moderate-to-severe blunt head trauma 6 or more months previously, were recruited from a large children's hospital medical center. Participants were randomized into a double-masked, placebo-controlled cross-over clinical trial. Participants completed a comprehensive neuropsychological battery and parent- and self-report ratings of everyday executive functioning at baseline, and at 4 weeks and 8 weeks following upward titration of medication to an optimal dose or while administered a placebo.

RESULTS

Methylphenidate was associated with significant improvements in processing speed, sustained attention, and both lab-based and everyday executive functioning. Significant treatment-by-period interactions were found on a task of sustained attention. Participants who were randomized to the methylphenidate condition for the first treatment period demonstrated random or erratic responding, with slower and more variable response times when given placebo during the second period.

CONCLUSION

Results indicate that methylphenidate treatment is associated with positive outcomes in processing speed, sustained attention, and both lab-based and everyday measures of executive functioning compared to placebo group. Additionally, results suggest sustained attention worsens when discontinuing medication. (JINS, 2019, 25, 740-749).

Methylphenidate and the risk of psychosis in adolescents and young adults: a population-based cohort study

BACKGROUND

There is a clinical concern that prescribing methylphenidate, the most common pharmacological treatment for attention-deficit hyperactivity disorder (ADHD), might increase the risk of psychotic events, particularly in young people with a history of psychosis. We aimed to determine whether the risk of psychotic events increases immediately after initiation of methylphenidate treatment or, in the longer term, 1 year after treatment initiation in adolescents and young adults with and without a previously diagnosed psychotic disorder.

METHODS

In this cohort study, we used population-based observational data from the Swedish Prescribed Drug Register, the National Patient Register, and the Total Population Register, three population-based registers containing data on all individuals in Sweden, to attain data on sex, birth, death, migration, medication use, and psychotic events for all eligible participants. We screened individuals on these registers to identify those receiving methylphenidate treatment, and who were aged 12-30 years at the start of treatment, for their inclusion in the study. We used a within-individual design to compare the incidence of psychotic events in these individuals during the 12-week periods immediately before and after methylphenidate initiation. Longer term risk was assessed by comparing the incidence of psychotic events 12 weeks before methylphenidate initiation and during a 12-week period one calendar year before the initiation of methylphenidate with the incidence of these events during the 12-week period one calendar year after methylphenidate initiation. We estimated the incidence rate ratios (IRR) and 95% CIs of psychotic events after the initation of methylphenidate treatment, relative to the events before treatment, which were defined as any hospital visit (inpatient admission or outpatient attendance, based on data from the National Patient Register) because of psychosis, using the International Classification of Diseases version 10 definition. Analyses were stratified by whether the individual had a history of psychosis.

FINDINGS

We searched the Swedish Prescribed Drug Register to find eligible individuals who had received methylphenidate between Jan 1, 2007 and June 30, 2012. 61 814 individuals were screened, of whom 23 898 (38·7%) individuals were assessed and 37 916 (61·3%) were excluded from the study because they were outside of the age criteria at the start of treatment, they had immigrated, emigrated, or died during the study period, or because they were administered other ADHD medications. The median age at methylphenidate initiation was 17 years, and a history of psychosis was reported in 479 (2·0%) participants. The IRR of psychotic events in the 12-week period after initiation of methylphenidate treatment relative to that in the 12-week period before treatment start was 1·04 (95% CI 0·80-1·34) in adolescents and young adults without a history of psychosis and 0·95 (0·69-1·30) among those with a history of psychosis.

INTERPRETATION

Contrary to clinical concerns, we found no evidence that initiation of methylphenidate treatment increases the risk of psychotic events in adolescents and young adults, including in those individuals with a history of psychosis. Our study should reassure clinicians considering initiating methylphenidate treatment for ADHD in adolescents and young adults, and it challenges the widely held view in clinical practice that methylphenidate should be avoided, or its use restricted, in individuals with a history of psychosis.

FUNDING

Swedish Research Council, National Institute of Mental Health, UK National Institute of Health Research Nottingham Biomedical Research Centre.

The Adult ADHD Quality Measures Initiative

Objective: Quality measures (QMs; also known as Quality Indicators) quantify health care processes, outcomes, patient perceptions, and organizational structure and/or systems that are relevant to the provision of high-quality health care. We describe the first phase of a project that has as its ultimate goal the creation and validation of QMs for tracking the screening, diagnosis, treatment, and clinical follow-up of adults with ADHD. This will fill an important gap in the field of Adult ADHD because QMs for adult ADHD do not exist. Method: We followed the guidelines of the U.S. Agency for Healthcare Research and Quality (AHRQ) for the development of QMs. These guidelines call for two phases: (1) Identify Candidate QMs and (2) Assess Candidate QMs. This article describes the results of our Phase 1 activities. To generate QMs for adult ADHD, we took the following steps: (a) searched the clinical/research literature for adult ADHD QMs; (b) convened a multidisciplinary panel comprising clinical and research experts and had them brainstorm potential QMs in the areas of screening, diagnosis, treatment, follow-up, care coordination, and patient experience; (c) compared these QMs with existing guidelines for adult ADHD to see if any potential QMs had been missed, this led to a draft list of 46 QMs; (d) had 28 ADHD experts rate the importance, reliability, validity, feasibility, and usability of the QMs. Results: The literature review found several QMs for ADHD in youth but none for ADHD in adults. The brainstorming session generated 52 QMs. The survey showed that all of these QMs were highly rated but that there was sufficient variability in ratings to prioritize some QMs over others. Conclusion: Based on these results, we prioritized QMs to carry forward into the next phase of the project. This work fills an important gap for the clinical care of adult patients with ADHD and helps to set a precedent for mental health, which has lagged behind other areas of medicine in developing QMs.