Factors associated with medium-term response to psychostimulant medication

Update on attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is now the most frequent diagnosis in children seen by Australian general paediatricians. It is a heterogeneous neurodevelopmental disorder and is usually accompanied by one or more co-morbid developmental and/or mental health conditions. In addition to daily symptoms, which often impair quality of life, ADHD can compromise educational and social development for the individual, and impact on families, schools and the broader community. Draft revised National Health and Medical Research Council Guidelines on ADHD were published in November 2009. This comprehensive document discusses the evidence in relation to many aspects of ADHD, which inform the large number of practice recommendations. Although there is an enormous literature on the causes, neurobiology and management of ADHD, there is still much to be learned particularly in relation to early intervention, behavioural therapies and factors influencing long-term outcomes.

Informants are not all equal: predictors and correlates of clinician judgments about caregiver and youth credibility

OBJECTIVE

The objectives of this study were to examine how often clinicians judged youths or caregivers to not be credible informants, to identify the associated features of youth or caregiver credibility, and to examine credibility's impact on the validity of mood and behavior checklists.

BACKGROUND

Clinicians often have the experience of talking to a parent or a youth and judging that the credibility of the information offered is unusually poor. Little is known about the correlates of poor credibility or about the extent to which credibility changes the validity of commonly used checklists.

METHODS

Interviewers rated the credibility of 646 youths aged 5-18 and their primary caregivers after completing a Kiddie Schedule for Affective Disorders and Schizophrenia. Ratings and diagnoses were blind to the behavior checklists completed by caregivers, youths, and teachers. A subset of youths also had intelligent quotient tests and behavioral observations available.

RESULTS

Caregivers were perceived as more credible on average than youths, though this dropped sharply with adolescents. Caregiver credibility was higher for better functioning families, more credible youths, younger youths, and more educated caregivers; it was unrelated to caregiver mood symptoms or being the mother. Youth credibility was strongly connected to age, cognitive ability, caregiver credibility, and independent observations of youth behavior. Credibility ratings markedly altered the validity of checklists compared with interview ratings, diagnoses, or cross-informant criteria.

CONCLUSION

Clinicians' judgments about informant credibility are associated with different characteristics for youths versus caregivers, though youth age is important to both. Credibility affects the validity of information from checklists measured against several different independent criteria.

Pharmacological management of attention-deficit hyperactivity disorder in adolescents: special considerations

Approximately one-half of children medicated for attention-deficit hyperactivity disorder (ADHD) will continue to experience sufficient impairment during adolescence to warrant the continuation of their treatment; a smaller number of people with ADHD may require treatment for the first time during adolescence. The academic and social demands of adolescence can exaggerate the impairment caused by attentional problems, as adolescents, more so than children, have activities in the afternoon and evening that will tax their attentional abilities. Stimulant and nonstimulant medications are likely to be as effective for adolescent patients as they are for younger children, provided treatment adherence is satisfactory. Long-acting medications are preferred over immediate-release compounds as they provide better coverage of symptoms throughout the day. Patterns of comorbidity with ADHD change from childhood to adolescence and may require a shift in treatment strategy. The choice of time to discontinue treatment should be a decision shared by the clinician and the patient. A negotiated trial of time off treatment followed by a review of the patient's symptoms can avert premature discontinuation of treatment.

Differentiating bipolar disorder in Turkish prepubertal children with attention-deficit hyperactivity disorder

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) and bipolar disorder (BPD) in children are frequently comorbid conditions. Because the coexistence of ADHD and mania seriously complicates the course of the condition and the treatment of children, diagnosing or missing this comorbidity has important clinical implications. There are very few systematic studies on the subject in the literature and BPD in children is not recognized or studied in most countries other than the USA. We aimed to differentiate Turkish prepubertal children with ADHD from those with comorbid ADHD and BPD and compare their clinical characteristics.

METHODS

A total of 147 treatment- and drug-naïve children, aged 7 to 13 years, who had been consecutively referred to the ADHD clinic, were evaluated using the Schedule for Affective Disorders and Schizophrenia for School-age Children-Present and Lifetime version (K-SADS-PL). Parents completed the Child Behavior Checklist (CBCL) 4-18 and the Parent-Young Mania Rating Scale (P-YMRS) prior to the clinical interview.

RESULTS

Twelve children (8.2%) had comorbid bipolar disorder (ADHD + BPD). The ADHD + BPD group had significantly higher rates of depressive disorders, oppositional defiant disorder, panic disorder and a family history of bipolar disorder compared with the ADHD group. The ADHD + BPD group had significantly more problems on the CBCL scale (anxiety/depression, social problems, thought problems, aggression, externalization, and total score) and on the P-YMRS (all items except for insight) compared with the ADHD group.

CONCLUSIONS

We conclude that ADHD + BPD in Turkish children represents a clinical picture different to that of ADHD alone, in which the clinical characteristics resemble those of children reported in the literature. Further long-term follow-up studies are needed in larger clinical and community samples.

Manic symptoms and behavioral dysregulation in youth with velocardiofacial syndrome (22q11.2 deletion syndrome)

Mania and bipolar disorder have been reported in adolescents and adults with velocardiofacial syndrome (VCFS; also known as 22q11.2 deletion syndrome). Children with VCFS have a high prevalence of attention-deficit/hyperactivity disorder (ADHD), which may constitute a risk factor for the eventual development of bipolar disorder in this population. Therefore, we sought to determine whether children with VCFS exhibit more manic symptoms than community controls that also may have learning disorders and ADHD. The study population consisted of 86 children with VCFS and 36 community controls from ages 9 to 15 years, using measures of Young Mania Rating Scale-Parent Version, Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL), Child Behavior Checklist (CBCL), and Wechsler Intelligence Scale for Children-3rd edition (WISC-III). The results indicate that manic symptoms were not more prevalent in VCFS than in a community sample of children with learning disorders and ADHD. However, after accounting for symptoms of depression and ADHD, we found that manic symptoms in VCFS predicted uniquely to scores on four Child Behavior Checklist (CBCL) subscales, including anxiety, somatization, thought, and conduct problems. In contrast, manic symptoms in controls predicted uniquely to conduct problems only. Accordingly, our findings of severe behavioral impairment in youth with VCFS and manic symptoms suggest that these children may warrant more intensive monitoring and treatment relative to youth with VCFS and ADHD only.

Diagnostic and measurement issues in the assessment of pediatric bipolar disorder: Implications for understanding mood disorder across the life cycle

The goal of this paper is to review assessment research of bipolar disorder in children and adolescents. The review addresses numerous themes: the benefits and costs of involving clinical judgment in the diagnostic process, particularly with regard to diagnosis and mood severity ratings; the validity of parent, teacher, and youth self-report of manic symptoms; how much cross-situational consistency is typically shown in mood and behavior; the extent to which a parent's mental health status influences their report of child behavior; how different measures compare in terms of detecting bipolar disorder, the challenges in comparing the performance of measures across research groups, and the leading candidates for research or clinical use; evidence-based strategies for interpreting measures as diagnostic aids; how test performance changes when a test is used in a new setting and what implications this has for research samples as well as clinical practice; the role of family history of mood disorder within an assessment framework; and the implications of assessment research for the understanding of phenomenology of bipolar disorder from a developmental framework.

Management of attention deficit hyperactivity disorder: a parental perspective

OBJECTIVES

There are few studies exploring parental perceptions of the diagnosis and overall treatment of their children with attention deficit hyperactivity disorder (ADHD). This community-based study was conducted to consider this important aspect of care.

METHODS

A total of 7 226 (65%) parents responded to a community survey of 11 184 children aged 10-12 years living in northern Sydney in 2000, out of which 278 children with ADHD were identified. Their parents completed an anonymous questionnaire covering their perceptions relating to diagnosis, treatment and overall management.

RESULTS

Only 66% of parents recalled the use of questionnaires or rating scales. There were 82% of children who had trialed medication and 66% of these were still taking it. Behavioural intervention had occurred in 42% of the children. Non-conventional treatments, most commonly elimination diet and/or fatty acid supplementation, had been used in 71% of the children. These were considered helpful in one-third of cases. A total of 55% of parents reported being either satisfied or very satisfied with their child's care. Parents were more likely to report satisfaction when their children were on medication and when reviews were held at least 6 monthly. Lack of educational support and teachers' understanding of ADHD were identified as ongoing issues.

CONCLUSION

Parental responses suggested that adherence to recommended diagnostic guidelines was inadequate. Behavioural intervention was underutilized despite its documented positive role. Non-conventional therapies were widely used and considered helpful in one-third of the children who used them. Use of stimulant medication and frequent reviews were more likely to be associated with overall management satisfaction.

Toward an Evidence-Based Assessment of Pediatric Bipolar Disorder

This article outlines a provisional evidence-based approach to the assessment of pediatric bipolar disorder (PBD). Public attention to PBD and the rate of diagnosis have both increased substantially in the past decade. Accurate diagnosis is crucial to avoid harm due to mislabeling or unnecessary medication exposure. Because there are no proven efficacious or effective treatments for PBD, the role of assessment is heightened to demonstrate efficacy in individual cases as well as to identify cases for participation in clinical trials. This review discusses (a) the state of psychopathology research regarding PBD; (b) the likely base rate of PBD in multiple clinical settings; (c) the diagnostic value of family history; (d) challenges to differential diagnosis, including comorbidity and symptom overlap with other diagnoses, shortcomings in contemporary assessment methods, and the cyclical nature of PBD; (e) practical methods for improving diagnosis, focusing on the most discriminative symptoms, extending the temporal window of assessment to capture mood changes, and using screening tools within an actuarial framework; and (f) monitoring response to treatment using a variety of assessment methods. Twelve recommendations are offered to move toward an evidence-based assessment model for PBD.

What is a clinically important level of improvement in symptoms of attention-deficit/hyperactivity disorder?

OBJECTIVE

To compare the desired and actual reduction in scores on a parent reported behaviour rating scale in a naturalistic sample of children and adolescents who had been treated with psychostimulant medication, referenced to global ratings of treatment benefit.

METHOD

Forty-five parents reporting poor global response to psychostimulant treatment, 44 reporting moderate response, and 49 reporting a high response retrospectively completed Conners rating scales describing their child prior to treatment, the child currently, and how the parent hoped the child would be following treatment.

RESULTS

Percentage actual improvement in behaviour rating scales from baseline ranged from around 25% for the poor responders to above 50% for the high responders. Desired improvement was above 50%, with no significant difference between the groups on level of expectation.

CONCLUSIONS

Percentage cut points used to indicate clinical improvement reported in previous controlled trials of psychostimulant medication are probably too low, and could lead to an overestimate of treatment effect. Expectation of treatment benefit is unlikely to contribute to variation in treatment response.

Employing parent, teacher, and youth self-report checklists in identifying pediatric bipolar spectrum disorders: an examination of diagnostic accuracy and clinical utility

The diagnosis of bipolar spectrum disorders (BPSD) is difficult to evaluate in child and adolescent populations. The current study examines whether commonly used behavior checklists- the Child Behavior Checklist, Teacher Report Form, and the Youth Self-Report form-are clinically useful in making a differential diagnosis between BPSD and other disorders. This study is the first to investigate the validity of integrating pairs of informants using these instruments to differentiate individuals with BPSD from those with disruptive behavior disorders, major depressive disorder, and any child or adolescent not meeting criteria for BPSD. Parent report best predicted diagnostic status, yet diagnostic efficiency statistics associated with these checklists were relatively poor. Results indicate that the Child Behavior Checklist has limited utility when attempting to derive clinically meaningful information about the presentation of juvenile BPSD.