Comparative Efficacy of Methylphenidate and Atomoxetine on Emotional and Behavioral Problems in Youths with Attention-Deficit/Hyperactivity Disorder

Increased post-COVID-19 behavioral, emotional, and social problems in Taiwanese children

BACKGROUND

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has remarkably impacted children's mental health. Investigating whether COVID-19-related behavioral changes persist after recovery from the acute phase of infection warrants investigation. The present study aimed to identify children's behavioral/emotional and social adjustment problems after SARS-CoV-2 infection.

METHODS

84 children aged 6-16 received assessments within 6 months after being tested positive for COVID-19. Their parents reported observations about their children 3 months before SARS-CoV-2 infection (pre-COVID condition) and the most recent 2 weeks (post-COVID condition) on a wide range of psychopathologies and social functional impairments. A control group consisted of 84 age-, sex-, and IQ-matched healthy children, with the same measures as those employed in the COVID group.

RESULTS

Compared with the control group, the COVID group in the post-COVID condition had more severe symptoms of inattention, hyperactivity-impulsivity, opposition, a wide range of emotional and behavioral problems, and poor school functions, school attitude, social interaction, school behavioral problems, and interaction problems with their parents. Compared with the pre-COVID condition, the COVID group had greater severity of inattention, somatic complaints, thought problems, internalizing problems, poor school functions, and interaction problems with their parents in the post-COVID condition.

CONCLUSIONS

The present study identified a significant link between SARS-CoV-2 infection and various post-COVID mental health sequelae in children, including behavioral/emotional and social adjustment challenges. Our results underline the importance of raising awareness about ongoing post-COVID mental health concerns in children.

Bioethical evaluation of methylphenidate and atomoxetine for pediatric ADHD and cognitive enhancement

BACKGROUND

This article presents a bioethical analysis of the use of Methylphenidate and Atomoxetine, exploring their roles as cognitive enhancers and therapeutic agents for Attention Deficit Hyperactivity Disorder (ADHD).

METHODS

The analysis centers around the principle of non-maleficence, examining the ethical implications of causing harm in the pursuit of cognitive enhancement and therapeutic benefits. It delves into the blurred boundaries between therapy and enhancement and the challenges of defining "necessary harm" in these contexts.

RESULTS

When used for cognitive enhancement rather than therapeutic purposes, methylphenidate challenges the concept of "necessary harm," raising ethical concerns about seeking improvement at the cost of potential adverse effects. The very notion of neurocognitive enhancement remains controversial in the absence of a clinical pathology. In pediatric ADHD, there is a significant lack of long-term data on both therapeutic benefits and adverse effects beyond 30 weeks of treatment. Clinical trials have highlighted safety concerns, as methylphenidate has been linked to sleep disturbances, anorexia, nervous conditions, and, in rare cases, cardiac events. Additionally, exposure during pregnancy may pose risks of congenital malformations. While atomoxetine generally has minor side effects, occasional reports of suicidal tendencies warrant caution.

DISCUSSION

The article discusses the philosophical and ethical underpinnings of human nature, individual autonomy, and the pursuit of enhancement, drawing on historical perspectives from figures like Julian Huxley and contemporary transhumanist ideals.

CONCLUSION

The study advocates for a cautious approach to cognitive enhancement, emphasizing the preservation of the individual's well-being over performance gains. In the context of ADHD treatment, it calls for an ethical examination of the long-term effects of Methylphenidate and Atomoxetine use in children and adolescents, recommending a preference for behavioral treatments when possible. Pediatric ADHD: There is a notable scarcity of data regarding the prevalence of therapeutic benefits and/or adverse effects in treatments exceeding 30 weeks. Furthermore, clinical trials concerning its safety and the lack of long-term data compromise the principle of non-maleficence, as we know that the use of Methylphenidate can lead to sleep disorders, anorexic conditions, nervous disorders, and has occasionally been associated with cardiac events. It also has effects on pregnancy that can lead to malformations in offspring. And although the unwanted effects associated with atomoxetine are generally minor, suicidal tendencies have been occasionally reported.

Multidimensional Comparison of Methylphenidate and Atomoxetine in the Treatment of Attention-Deficit/Hyperactivity Disorder in Children, a 12-Week, Open-Label, Head-to-Head Clinical Trial

OBJECTIVE

To compare the treatment efficacy of methylphenidate and atomoxetine on core symptoms, behavioral and emotional problems, and executive function in children with attention-deficit/hyperactivity disorder (ADHD).

METHODS

Sixty children with ADHD diagnosed by the fifth edition Diagnostic and Statistical Manual of Mental Disorders in Tangshan Maternal and Child Health Hospital from 2023 to 2024 were randomly divided into methylphenidate and atomoxetine groups. Core symptoms were assessed using the Parent Swanson, Nolan, and Pelham, Version IV Scale (SNAP-IV) and Integrated Visual and Auditory Continuous Performance Test (IVA-CPT). Behavioral and emotional problems were administered via the Conners Parent Symptom Questionnaire (PSQ) and executive function was evaluated utilizing the Wisconsin Card Sorting Test (WCST) and Digit Span Test (DST). All data were analyzed using SPSS 26.00 to identify discrepancies.

RESULTS

When contrasted with the methylphenidate and atomoxetine groups at 12 weeks, their mean efficiency was no significant disparity (p>0.05). Notable statistical differences were evident in IVA-CPT, the inattention, hyperactivity-impulsivity of SNAP-IV, and the psychosomatic disorder, anxiety, and hyperactivity-impulsivity of PSQ (p<0.05), yet in hyperactivity index, conduct, and learning difficulties of PSQ (p>0.05). No statistical significance was attributed to DST and the number of completed categories in WCST (p>0.05) but to response errors and perseverative errors (p<0.05).

CONCLUSION

Although both methylphenidate and atomoxetine are capable of effectively ameliorating ADHD, methylphenidate demonstrates a superior ability to improve core symptoms of ADHD, as well as address conduct problems, cognitive transfer abilities, and frontal lobe function in pediatric patients. Conversely, atomoxetine is the best choice for cases comorbid with anxiety.

Effects of Methylphenidate and Atomoxetine Treatment on Improvement of Motor Coordination in Children With Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

To investigate the effects of methylphenidate and atomoxetine treatment on motor coordination in children with attention-deficit/hyperactivity disorder (ADHD).

METHODS

In this single-site, open-label, naturalistic follow-up study, 157 children (7.6±1.4 years; 139 males) with ADHD were recruited between March 2015 and May 2020 from the Department of Psychiatry, Asan Medical Center, and treated for 12 weeks with methylphenidate (n=48) or atomoxetine (n=109). Children completed the Advanced Test of Attention (ATA), and caregivers completed the ADHD Rating Scale (ARS) questionnaire and Developmental Coordination Disorder Questionnaire (DCDQ) at baseline and at 12 weeks. Paired t-tests, a mixed-effects model, and linear regression were used to compare treatment groups and assess factors influencing motor coordination changes.

RESULTS

Methylphenidate and atomoxetine resulted in significant improvement in DCDQ fine motor/handwriting, general coordination, and total scores over 12 weeks. Fine motor/handwriting had a significant main effect for time (F1=16.64, p<0.001, η2=0.097); however, the interaction effect between group and time was not significant (F1=0.24, p=0.625, η2=0.002). Changes in parent-reported ARS inattention scores (β=-0.174, p=0.029) and auditory commission errors of ATA (β=0.191, p=0.022) were significantly associated with changes in fine motor/handwriting. Additionally, changes in parent-reported ARS inattention scores (β=-0.177, p=0.034) and rater-reported ARS inattention scores (β=-0.198, p=0.017) were significant predictors of improvements in general coordination in separate models.

CONCLUSION

Methylphenidate and atomoxetine had a positive effect on motor coordination in children with ADHD. Improvement in motor coordination was associated with ADHD symptom improvement.

A Post-Hoc Analysis of Emotional Lability With Delayed-Release/Extended-Release Methylphenidate in Children Aged 6 to 12 Years of Age Participating in Two Phase 3 Clinical Trials

OBJECTIVE

DR/ER-MPH (formerly HLD200) is an evening-dosed delayed-release and extended-release methylphenidate approved for the treatment of ADHD in patients ≥6 years. Post hoc analyses of two pivotal Phase 3 trials: HLD200-107 (NCT02493777) and HLD200-108 (NCT02520388) evaluated emotional lability (EL) with DR/ER-MPH treatment.

METHODS

Differences in Conners Global Index-Parent (CGI-P) EL subscale scores and age- and gender-adjusted T-scores over an open-label titration phase (HLD200-107) and between treatment and placebo groups at endpoint (HLD200-108) were evaluated.

RESULTS

In HLD200-107 (N = 117) mean CGI-P EL subscale scores improved from 5.3 to 1.3 (p < .0001) after 6 weeks; in HLD200-108 significant improvements were observed in the treatment group (n = 81) versus placebo (n = 80; 3.11 vs. 4.08; p = .0053). T-scores showed an improvement with DR/ER-MPH treatment in both trials. Few emotional adverse events (AEs) were reported.

CONCLUSION

DR/ER-MPH treatment resulted in statistically significant improvements in EL to the level of non-ADHD peers as contextualized by T-scores.

Anxiety and Somatic Symptoms in Children and Adolescents Diagnosed with Attention-Deficit Hyperactivity Disorder

Background

Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental condition typified by inattention, hyperactivity, and impulsivity. Comorbid psychiatric disorders are common among children and adolescents with ADHD. In this study, it was aimed to examine anxiety and somatic symptoms in children and adolescents with ADHD and the effect of methylphenidate treatment on these symptoms.

Method

Three groups were formed, consisting of 37 children and adolescents diagnosed with ADHD and received methylphenidate treatment, 37 newly diagnosed, treatment-naive children and adolescents with ADHD diagnosis, and 37 children and adolescents without the diagnosis of ADHD. The symptoms of ADHD in children were examined by using the DSM-IV-based child and adolescent behavior disorders screening and rating scale, the symptoms of anxiety were examined by using the screen for child anxiety-related disorders (SCARED), and somatic symptoms were examined by using the DSM-5 level 2 somatic symptom scale.

Results

In the newly diagnosed, treatment-naive with ADHD group, anxiety and somatic symptoms were found to be significantly higher compared to the ADHD group with methylphenidate treatment and the non-ADHD group. It was shown that the symptoms of panic disorder, generalized anxiety, and social phobia were observed more in the newly diagnosed, treatment-naive with ADHD group compared to the treatment group with ADHD.

Conclusions

It was determined that children and adolescents diagnosed with ADHD had more anxiety and somatic symptoms. Anxiety and somatic symptoms increased as the severity of ADHD symptoms increased. Anxiety and somatic symptoms were lower than in ADHD children receiving methylphenidate treatment. Clinicians should keep in mind to evaluate anxiety and somatic symptoms in children and adolescents with ADHD before the treatment.

Psychopharmacological treatment of disruptive behavior in youths: systematic review and network meta-analysis

To conduct a systematic review of the comparative efficacy of various psychotropic medications for the treatment of disruptive behavior (DBs) in youths. To this aim, we systematically reviewed randomized clinical trials (RCTs) of various psychotropic medications targeting symptoms of DBs and applied network meta-analysis to investigate their relative efficacy. Fifty-five RCTs meeting the inclusion criteria were selected. To predict and interpret relative treatment efficacy, we compared the efficacy of various psychotropic medications prescribed for DB symptoms based on their mechanism of action. Network meta-analysis revealed that for reducing DBs, second-generation antipsychotics, stimulants, and non-stimulant ADHD medications were more efficacious than placebo, and second-generation antipsychotics were the most efficacious. The dopaminergic modulation of top-down inhibitory process by these medications is discussed in this review. This study offers information on the relative efficacy of various psychotropic medications for the treatment of DB, and insight into a potential neurobiological underpinning for those symptoms. It also illustrates the potential utility of these neurobiological mechanisms as a target for future treatment studies.

Effects of Methylphenidate on Somatic Symptoms and Brain Functional Connectivity in Adolescents with Attention Deficit Hyperactivity Disorder: A Pilot Study

Objective

This study aimed to evaluate whether somatic symptoms in adolescents with attention deficit hyperactivity disorder (ADHD) are associated with a dissociative pattern of functional connectivity (FC) within the default mode network (DMN) and whether methylphenidate administration can improve clinical and somatic symptoms. We also evaluated whether the improvement of somatic symptoms is associated with increased FC within the DMN in response to methylphenidate treatment.

Methods

Fifteen male adolescents with somatic symptoms of ADHD and 15 male adolescents with ADHD without somatic symptoms were included. At baseline and after 6 months of methylphenidate treatment, all adolescents were asked to complete questionnaires for the Korean version of the Dupaul’s ADHD rating scale, the symptom checklist-90- revised-somatization subscales, the Beck Depression Inventory, and the Beck Anxiety Inventory. Additionally, a resting-state functional magnetic resonance imaging scan was conducted.

Results

Methylphenidate treatment improved clinical and somatic symptoms in adolescents with ADHD. In addition, it increased brain FC within the DMN from the posterior cingulate cortex (posterior DMN) to the middle prefrontal cortex (anterior DMN). The improvement of somatic symptoms was associated with FC within the DMN from the posterior cingulate cortex to the middle prefrontal cortex in ADHD adolescents with somatic symptoms.

Conclusion

Methylphenidate increased brain FC between the anterior and posterior DMN. The improvement of somatic symptoms in adolescents with ADHD was associated with FC within the DMN. The DMN in adolescents with ADHD seems to be associated with the severity of the clinical and somatic symptoms of ADHD.

A Randomized, Double-Blind, Placebo-Controlled, Two-Way Crossover Clinical Trial of ORADUR-Methylphenidate for Treating Children and Adolescents with Attention-Deficit/Hyperactivity Disorder

Objective: Methylphenidate (MPH) is efficacious in reducing symptoms of attention-deficit/hyperactivity disorder (ADHD), but there are no data about the efficacy and safety of its new formulation (ORADUR^®-MPH extended release, ORADUR-MPH) in patients with ADHD, which is the study objective. Method: This was a Phase III, multicenter, randomized, double-blind, placebo-controlled, two-way crossover clinical trial. One hundred children and adolescents with a clinical diagnosis of ADHD (72.7% male) received at least one dose of ORADUR-MPH or a placebo during the 2-week treatment period of each phase. The primary efficacy measure was the Swanson, Nolan, and Pelham-IV-teacher (SNAP-IV-T) form. Secondary efficacy measures included the SNAP-IV-parent form, the Clinical Global Impression: ADHD-Severity score, the Conner's Teacher's Rating Scale score, and the investigator's rating for 18 Diagnostic and Statistical Manual of Mental Disorders, 5th edition ADHD symptoms. In addition, data related to vital signs, body weight, physical examination, laboratory testing, and adverse events (AEs) were also collected. All data were analyzed on an intent-to-treat basis. Results: Without adjusting for differences in demographics and baseline measures, both treatment groups showed significant reductions in ADHD and oppositional defiant disorder symptoms after a 2-week treatment with greater effect sizes (Cohen's d) in the ORADUR-MPH group (Cohen's d ranging from -0.41 to -1.64; placebo, Cohen's d ranging from -0.26 to -1.18), except for oppositional symptoms, regardless of the informants. For the primary efficacy measure, ORADUR-MPH was significantly superior to the placebo, as evidenced by lower values for and greater reductions in the SNAP-IV-T scores at the endpoint (Cohen's d = -0.16, p = 0.005) and from baseline to the endpoint (Cohen's d = -0.19, p = 0.006), respectively. There were no serious AEs during the clinical study period. The most frequently observed AE was decreased appetite (49.1%). Most physical and laboratory test variables remained within the normal range. Conclusions: Once-daily ORADUR-MPH is an effective, well-tolerable, and safe treatment for children and adolescents with ADHD. ClinicalTrials.gov number, NCT02450890.

Utilization of Drugs for Attention-Deficit Hyperactivity Disorder Among Young Patients in China, 2010-2019

OBJECTIVE

The use of attention-deficit hyperactivity disorder (ADHD) medication is increasing worldwide, but its status in China is unknown. This research aimed to assess the trends of ADHD medication use in young Chinese patients between 2010 and 2019.

METHODS

Dispensing data related to ADHD medication use were extracted from the Hospital Prescription Analysis Cooperative Project of China. The trends in the yearly prescription number of ADHD drugs and corresponding cost were analyzed. We further stratified the data by age, sex, and specific drug.

RESULTS

From 2010 to 2019, sampled prescriptions for ADHD medication increased from 902 to 4531, and the total expenditure increased rapidly from 276,580 to 2,412,308 Chinese Yuan. Prescriptions for males were almost fourfold more than that for females. Patients aged 6-11 years had the highest number of prescriptions for ADHD medication each year, accounting for more than 50% of the total number of prescriptions. The percentage of methylphenidate prescriptions decreased from 91.9% in 2010 to 76.9% in 2019, and the corresponding cost declined from 77.3% to 66.8%. In contrast, atomoxetine prescriptions increased progressively and accounted for about 24.5% of the total prescriptions at the end of the study.

CONCLUSIONS

The use of ADHD drugs and the corresponding cost increased rapidly in China, and methylphenidate was the most frequently prescribed medicine. The increase in ADHD prescriptions requires attention to ensure that it reflects appropriate use, especially in patients aged 6-11 years.

The Mechanism, Clinical Efficacy, Safety, and Dosage Regimen of Atomoxetine for ADHD Therapy in Children: A Narrative Review

Atomoxetine, a selective norepinephrine (NE) reuptake inhibitor, was approved for attention deficit/hyperactivity disorder (ADHD) treatment in children, adolescents and adults. We searched the database PubMed/MEDLINE (2000 to October 1, 2021). Only publications in English were considered. Atomoxetine inhibits the presynaptic norepinephrine transporter (NET), preventing the reuptake of NE throughout the brain along with inhibiting the reuptake of dopamine in specific brain regions such as the prefrontal cortex (PFC). The novel mechanism of atomoxetine also includes several new brain imaging studies and animal model studies. It is mainly metabolized by the highly polymorphic drug metabolizing enzyme cytochrome P450 2D6 (CYP2D6). Atomoxetine is effective and generally well tolerated. ADHD is often accompanied by multiple comorbidities. A series of studies have been published suggesting that atomoxetine is effective in the treatment of ADHD symptoms for children with various types of comorbidity. In some cases, it is possible that atomoxetine may have a positive influence on the symptoms of comorbidities. Atomoxetine can be administered either as a single daily dose or split into two evenly divided doses, and has a negligible risk of abuse or misuse. The latest guideline updated that clinical dose selection of atomoxetine was recommended based on both CYP2D6 genotype and the peak concentration. To have a more comprehensive understanding of atomoxetine, this review sets the focus on the mechanism, clinical efficacy and dosage regimen in detail, and also touches on those studies regarding adverse reactions of atomoxetine.

Comparative Efficacy of Methylphenidate and Atomoxetine on Social Adjustment in Youths with Attention-Deficit/Hyperactivity Disorder

Objective: Although methylphenidate and atomoxetine have positive effects in reducing core symptoms and emotional/behavioral problems of attention-deficit/hyperactivity disorder (ADHD), little is known about their efficacy in improving social adjustment problems among youths with ADHD. Methods: A total of 168 drug-naive youths, 7-16 years of age, with DSM-IV-defined ADHD, were recruited and randomly assigned to osmotic-release oral system methylphenidate (n = 83) and atomoxetine (n = 85) in a 24-week, open-label, head-to-head clinical trial. Efficacy measurement was based on the parent-rated and self-rated Social Adjustment Inventory for Children and Adolescents (SAICA). Evaluation time points were set at baseline and weeks 8, 16, and 24. Results: At week 24, methylphenidate was associated with improvement in school functions (parent report: Cohen d = -0.82; self-report: Cohen d = -0.66) and peer relationships (parent report: Cohen d = -0.50; self-report: Cohen d = -0.25); and atomoxetine was associated with improvement in school functions (parent report: Cohen d = -0.62; self-report: Cohen d = -0.34) and peer relationships (parent report: Cohen d = -0.33; self-report: Cohen d = -0.65). In terms of parent-reported and self-reported ratings, there were no significant differences between the two treatment groups in mean reduction in the severity of school dysfunctions, impaired peer relationships, and behavioral problems at home at week 24. Conclusions: Our findings lend evidence to support that both methylphenidate and atomoxetine were comparably effective in improving social adjustment in youths with ADHD, including school functions and peer relationships.