Quantifying the Protective Effects of Stimulants on Functional Outcomes in Attention-Deficit/Hyperactivity Disorder: A Focus on Number Needed to Treat Statistic and Sex Effects

Randomized, Double-Blind, Placebo-Controlled Trial on the Efficacy, Safety and Tolerability of Modified-Release Methylphenidate (MPH-MR) in Chinese Children and Adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD)

BACKGROUND AND OBJECTIVES

The efficacy and safety of modified-release methylphenidate (MPH-MR) in the treatment of attention-deficit/hyperactivity disorder (ADHD) have been shown in both pediatric and adult Caucasian patients. The objective of this study was to assess the efficacy and safety of MPH-MR in Chinese children and adolescents with ADHD.

METHODS

MICCA was a randomized, double-blind, placebo-controlled trial conducted at 19 sites in China from September 2018 to July 2021. The study enrolled children and adolescents aged 6 to < 18 years with a primary diagnosis of ADHD according to the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5). Patients were randomized 1:1 to once-daily MPH-MR (10-60 mg) or placebo. The study included an up-titration phase of up to 5 weeks and a dose maintenance phase of 4 weeks. The primary efficacy endpoint was the change in the ADHD Rating Scale-IV (ADHD-RS-IV) total score from baseline to the end of the maintenance phase (EoM). Secondary endpoints included the change from baseline to EoM in Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P) total score, and Clinical Global Impression-Improvement (CGI-I) scores at EoM. Safety assessments included treatment-emergent adverse events (TEAEs) and vital signs.

RESULTS

A total of 221 patients were randomized (MPH-MR: n = 110; placebo: n = 111). The change in the ADHD-RS-IV total score from baseline to EoM was significantly greater for MPH-MR versus placebo, with a least squares (LS) mean (95% confidence interval [CI]) treatment difference of - 4.6 (- 6.92, - 2.30) (p < 0.001). The mean (95% CI) treatment difference for the WFIRS-P total score change from baseline to EoM also significantly favored MPH-MR over placebo (- 6.46 [- 10.57, - 2.34]; p = 0.002). The CGI-I score at EoM was significantly lower in the MPH-MR group compared to the placebo group (2.2 vs 2.5; p = 0.002). Treatment-emergent adverse events were reported for 74 (67.3%) patients in the MPH-MR group and 55 (49.1%) patients in the placebo group. Most TEAEs were mild to moderate in severity. The most common TEAEs for MPH-MR were decreased appetite, nausea and upper respiratory tract infection. Treatment-emergent adverse events leading to study drug discontinuation/study withdrawal were reported in 4 (3.6%) patients in the MPH-MR group and 1 (0.9%) patient in the placebo group. No clinically relevant changes in vital signs were observed during the study.

CONCLUSIONS

Modified-release methylphenidate was superior to placebo in improving ADHD symptoms and functioning in Chinese pediatric patients with ADHD. Modified-release methylphenidate had a good safety and tolerability profile. Trial Registration http://www.chinadrugtrials.org.cn/ Identifier: CTR20180056 (registered on 21 May 2018).

In Memoriam: Professor Joseph Biederman's Contributions to Child and Adolescent Psychiatry

OBJECTIVE

To provide an overview of Joe Biederman's contributions to child and adolescent psychiatry.

METHOD

Nine colleagues described his contributions to: psychopharmacology, comorbidity and genetics, pediatric bipolar disorder, autism spectrum disorders, Tourette's and tic disorders, clinical and neuro biomarkers for pediatric mood disorders, executive functioning, and adult ADHD.

RESULTS

Joe Biederman left us with many concrete indicators of his contributions to child and adolescent psychiatry. He set up the world's first pediatric psychopharmacology clinic and clinical research program in child adolescent psychiatry. As a young faculty member he began a research program that led to many awards and eventual promotion to full professor at Harvard Medical School. He was for many years the most highly cited researcher in ADHD. He achieved this while maintaining a full clinical load and was widely respected for his clinical acumen.

CONCLUSION

The world is a better place because Joe Biederman was here.

Central executive training for ADHD: Impact on organizational skills at home and school. A randomized controlled trial

OBJECTIVE

The current randomized controlled trial (RCT) was the first to examine the benefits of central executive training (CET, which trains the working components of working memory [WM]) for reducing organizational skills difficulties relative to a carefully matched neurocognitive training intervention (inhibitory control training [ICT]).

METHOD

A carefully phenotyped sample of 73 children with attention-deficit/hyperactivity-impulsivity disorder (ADHD; ages 8-13, M = 10.15, SD = 1.43; 20 girls; 73% White/Non-Hispanic) participated in a preregistered RCT of CET versus ICT (both 10-week treatments). Parent-rated task planning, organized actions, and memory/materials management data were collected at pretreatment, posttreatment, and 2-4 month follow-up; teacher ratings were obtained at pretreatment and 1-2 month follow-up.

RESULTS

CET was superior to ICT for improving organizational skills based on teacher report (Treatment × Time interaction: d = 0.61, p = .01, BF₁₀ = 31.61). The CET group also improved significantly based on parent report, but this improvement was equivalent in both groups (main effect of time: d = 0.48, p < .001, BF₁₀ = 3.13 × 10⁷; Treatment × Time interaction: d = 0.29, p = .25, BF₀₁ = 3.73). Post hocs/preregistered planned contrasts indicated that CET produced significant and clinically meaningful (number needed to treat = 3-8) pre/post gains on all three parent (d = 0.50 -0.62) and all three teacher (d = 0.46 -0.95) subscales, with gains that were maintained at 1-2 month (teacher report) and 2-4 month follow-up (parent report) for five of six outcomes.

CONCLUSIONS

Results provide strong initial evidence that CET produces robust and lasting downstream improvements in school-based organizational skills for children with ADHD based on teacher report. These findings are generally consistent with model-driven predictions that ADHD-related organizational problems are secondary outcomes caused, at least in part, by underdeveloped working memory abilities. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Growth Trajectories in Stimulant Treated Children and Adolescents: A Qualitative Review of the Literature from Comprehensive Datasets and Registries

Objective: Attention-deficit/hyperactivity disorder (ADHD) treatment with stimulant products has been shown to be safe and effective; however, there are remaining concerns about their possible adverse effects on growth trajectories. We conducted a systematic review of the extant literature derived from ecologically valid databases and registries to assess the body of knowledge about the effects of stimulants on growth trajectories in naturalistic samples. Methods: Using PubMed and PsycINFO, we searched for articles published before February 8, 2023 that focused on growth findings associated with stimulant treatment in pediatric ADHD from comprehensive datasets derived from naturalistic population studies. Results: Of the 1070 articles initially identified, 12 met all inclusion criteria. Sample sizes ranged from 157 to 163,820 youths. Seven of 10 articles examining height found significant decreases in height associated with chronic stimulant treatment that normalized over time in 2 studies. Three articles found no significant association between stimulant treatment and height. No clear associations were identified between cumulative duration and dose of stimulant treatment and adult height. All articles examining weight and six of eight articles examining body mass index (BMI) found significant initial decreases that tended to normalize then increase over time. Longer duration of stimulant medication use was predominantly associated with significant weight and BMI reductions. The effects of stimulant dose on weight and BMI were mostly weak and clinically insignificant. Most studies found no significant association between age at start of stimulant treatment and change in height, weight, or BMI. Most studies did not find significant sex effects in relation to growth parameters. Conclusions: This review of ecologically informative samples revealed that the effects of stimulant treatment on growth trajectories are mainly small and transient. These effects seem to be clinically insignificant for most youth with ADHD who receive stimulant treatment from childhood onto adolescence and adulthood.

Examining the impact of ADHD polygenic risk scores on ADHD and associated outcomes: A systematic review and meta-analysis

Early identification of attention-deficit/hyperactivity disorder (ADHD) is critical for mitigating the many negative functional outcomes associated with its diagnosis. Because of the strong genetic basis of ADHD, the use of polygenic risk scores (PRS) could potentially aid in the early identification of ADHD and associated outcomes. Therefore, a systematic search of the literature on the association between ADHD and PRS in pediatric populations was conducted. All articles were screened for a priori inclusion and exclusion criteria, and, after careful review, 33 studies were included in our systematic review and 16 studies with extractable data were included in our meta-analysis. The results of the review were categorized into three common themes: the associations between ADHD-PRS with 1) the diagnosis of ADHD and ADHD symptoms 2) comorbid psychopathology and 3) cognitive and educational outcomes. Higher ADHD-PRS were associated with increased odds of having a diagnosis (OR = 1.37; p<0.001) and more symptoms of ADHD (β = 0.06; p<0.001). While ADHD-PRS were associated with a persistent diagnostic trajectory over time in the systematic review, the meta-analysis did not confirm these findings (OR = 1.09; p = 0.62). Findings showed that ADHD-PRS were associated with increased odds for comorbid psychopathology such as anxiety/depression (OR = 1.16; p<0.001) and irritability/emotional dysregulation (OR = 1.14; p<0.001). Finally, while the systematic review showed that ADHD-PRS were associated with a variety of negative cognitive outcomes, the meta-analysis showed no significant association (β = 0.08; p = 0.07). Our review of the available literature suggests that ADHD-PRS, together with risk factors, may contribute to the early identification of children with suspected ADHD and associated disorders.

From Structural Disparities to Neuropharmacology: A Review of Adult Attention-Deficit/Hyperactivity Disorder Medication Treatment

Adult attention-deficit/hyperactivity disorder (ADHD) is an early-onset disorder with many functional impairments and psychiatric comorbidities. Although no treatment fully mitigates impairments associated with ADHD, effective management is possible with pharmacologic and nonpharmacologic treatments. The etiology and pathophysiology of ADHD are remarkably complex and the disorder is continuously distributed in the population. While these findings have been well documented in studies with predominantly white samples, ADHD may affect racial and ethnic minorities differentially, given diagnostic and treatment disparities. This review provides an updated overview of the epidemiology, etiology, neurobiology, and neuropharmacology of ADHD, addressing racial and ethnic disparities whereby data are available.

Updates in Pharmacologic Strategies in Adult Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) significantly worsens quality of life and long-term functional outcomes in adults. Individual impairments in adults with ADHD can be further contextualized within considerable costs to society at large. Food and Drug Administration (FDA) approved stimulants and nonstimulant medications can significantly improve ADHD symptoms in adults. In the past 2 decades, the United States FDA has expanded approval of pharmacotherapeutic options for adult ADHD. However, limitations still persist in available psychotropics for certain patient populations such as those with comorbid substance use or cardiovascular illness. Clinicians therefore must appreciate several ongoing investigations into medications with unique mechanisms of action. This article reviews the current FDA approved and emerging medication options while providing guidelines for pharmacologic management of adult ADHD.

Central executive training for ADHD: Effects on academic achievement, productivity, and success in the classroom

OBJECTIVE

Central executive training (CET) is a "Level 2" evidence-based treatment for improving ADHD-related executive dysfunction and behavioral symptoms, but the extent to which these gains extend to the disorder's well-documented academic difficulties is unknown.

METHOD

Across two clinical trials, 108 children with attention-deficit/hyperactivity disorder (ADHD) 8-13 years old (M = 10.29, SD = 1.50; 32 girls; 75% White/Non-Hispanic) were treated with CET (n = 52), inhibitory control training (ICT; n = 29), or gold-standard behavioral parent training (BPT; n = 27).

RESULTS

CET was superior to BPT and ICT (d = 0.62-0.88) for improving masked teacher perceptions of academic success, impulse control, and academic productivity at 1-2 months posttreatment. At 2-4-month follow-up, CET (d = 0.76) and ICT (d = 0.54) were superior to BPT for improving objectively-tested academic achievement overall (reading comprehension, math problem-solving, language comprehension), and CET was superior to ICT (d = 0.56) for improving math problem-solving. The significant benefits of CET on academic success, academic productivity, reading comprehension, and math problem-solving replicated across both trials and were clinically significant as evidenced by low number needed to treat estimates (Needed to Treat; NNT = 3-7) and significantly higher proportions of individual cases demonstrating reliable improvements in academic success/productivity (33%-36% vs. 0%-18%) and achievement (38%-72% vs. 18%-54%) across outcomes (all p ≤ .01).

CONCLUSIONS

Results across the two trials provide strong support for the efficacy of CET for ADHD, and are consistent with model-driven hypotheses that academic difficulties in ADHD are due, in part, to these children's underdeveloped executive functioning abilities. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A review of Cochrane reviews on pharmacological treatment for attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is one of the most frequent childhood psychiatric problems.

Objective

The objective of this study was to identify, synthesize the results, and critically evaluate all Cochrane systematic reviews (SRs) on the pharmacological interventions for children and adolescents (up to age 18) diagnosed with ADHD.

Methods

The search was performed in the Cochrane Database of Systematic Reviews (via Wiley) in July 2020.

Results

The search strategy resulted in four SRs of high methodological quality, analyzing 51 randomized clinical trials (9,013 participants). Compared to placebo, treatment with tricyclic antidepressants (TCAs) (desipramine), amphetamine, and methylphenidate showed improvement in symptoms such as difficulty concentrating, impulsivity, and hyperactivity in the short term (up to 6 months). There was an increase in the occurrence of adverse events, such as reduced appetite, difficulty sleeping, and abdominal pain. Insufficient evidence was found to support the effects of supplementation with polyunsaturated fatty acids.

Conclusions

The use of TCAs, amphetamine, and methylphenidate in children and adolescents with ADHD seems to present positive effects and higher rates of minor adverse events when compared to placebo.

Individualization of attention-deficit/hyperactivity disorder treatment: pharmacotherapy considerations by age and co-occurring conditions

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that manifests in childhood and can persist into adolescence and adulthood. Impairments associated with ADHD can impact quality of life, social interactions, and increase the risk of morbidity and mortality; however, for many patients, effective treatment can lessen these effects. Pharmacotherapy with stimulants or nonstimulants is recommended in conjunction with psychosocial therapy for most patients. Determining the optimal pharmacotherapy can be complex, and the clinician needs to consider many factors such as the patient's age, comorbidities, and lifestyle. Furthermore, the needs of the patient with ADHD will change over time, with specific challenges to consider at each stage of life. A variety of Food and Drug Administration (FDA)-approved stimulant and nonstimulant formulations are available with different modes of delivery and durations of effect. This armamentarium of ADHD medications can be used to individualize ADHD treatment for each patient's needs. This article combines current information from the literature and the first-hand experience of the authors to provide guidance on ADHD treatment options for patients of different ages and for some of the more common comorbidities.

Management of anxiety disorders in children with attention-deficit hyperactivity disorder: a narrative review

Anxiety disorders are common comorbidities of attention deficit/hyperactivity disorder (ADHD) and conversely, ADHD is prevalent among anxious youths. A variety of treatments, both psychopharmacological and nonpsychopharmacological, are used to manage combined ADHD/anxiety disorder. This article aims to review the literature on the treatment of ADHD with comorbid anxiety disorders, and make evidence-based recommendations for clinical practice. In most cases, when ADHD is the primary condition, stimulants are the first-line of treatment, frequently resulting not only in improvement in ADHD symptoms but also alleviating the symptoms of the comorbid anxiety disorder. Stimulant treatment is relatively safe and well-tolerated in ADHD with comorbid anxiety disorder. When the stimulant administration does not attenuate the severity of the comorbid anxiety disorder, a treatment that targets specifically the anxiety disorder should be added. This recommendation, however, might be challenged by the impressive efficacy of atomoxetine for both the ADHD and anxiety disorder symptoms. Adjunctive cognitive-behavior therapy for anxiety disorder symptoms is strongly recommended and is considered superior to medication alone. Other options include adding pharmacological treatment for the anxiety symptoms. In moderate and severe cases of comorbid Ads, selective serotonin reuptake inhibitors can be added to the stimulants, with the required caution.

A literature review and meta-analysis on the effects of ADHD medications on functional outcomes

OBJECTIVE

To conduct a systematic review and meta-analysis of literature from large databases and registries to assess the effects of ADHD medication on associated functional outcomes.

STUDY DESIGN

A literature search was performed in PubMed, PsycINFO, MEDLINE, and Web of Science for articles published prior to January 2019. Sample size, age range, country of origin, medication type, number of functional events and non-events, odds ratios and hazard ratios, and means and standard deviations were extracted. Random-effects meta-analyses were conducted for 21 studies examining functional outcomes.

RESULTS

40 articles were included. The majority suggest a robust protective effect of ADHD medication treatment on mood disorders, suicidality, criminality, substance use disorders, accidents and injuries, traumatic brain injuries, motor vehicle crashes, and educational outcomes. Similarly, the meta-analyses demonstrated a protective effect of medication treatment on academic outcomes, accidents and injuries, and mood disorders.

CONCLUSIONS

These findings suggest that ADHD medication treatments are associated with decreases in the risks for a wide range of ADHD-associated functional outcomes supporting efforts aimed at early diagnosis and treatment of individuals with ADHD.