ADHD in children and youth: Part 2-Treatment

Impact of COVID-19 pandemic on prescription stimulant use among children and youth: a population-based study

COVID-19 associated public health measures and school closures exacerbated symptoms in some children and youth with attention-deficit hyperactivity disorder (ADHD). Less well understood is how the pandemic influenced patterns of prescription stimulant use. We conducted a population-based study of stimulant dispensing to children and youth ≤ 24 years old between January 1, 2013, and June 30, 2022. We used structural break analyses to identify the pandemic month(s) when changes in the dispensing of stimulants occurred. We used interrupted time series models to quantify changes in dispensing following the structural break and compare observed and expected stimulant use. Our main outcome was the change in the monthly rate of stimulant use per 100,000 children and youth. Following an initial immediate decline of 60.1 individuals per 100,000 (95% confidence interval [CI] - 99.0 to - 21.2), the monthly rate of stimulant dispensing increased by 11.8 individuals per 100,000 (95% CI 10.0-13.6), with the greatest increases in trend observed among females, individuals in the highest income neighbourhoods, and those aged 20 to 24. Observed rates were between 3.9% (95% CI 1.7-6.2%) and 36.9% (95% CI 34.3-39.5%) higher than predicted among females from June 2020 onward and between 7.1% (95% CI 4.2-10.0%) and 50.7% (95% CI 47.0-54.4%) higher than expected among individuals aged 20-24 from May 2020 onward. Additional research is needed to ascertain the appropriateness of stimulant use and to develop strategies supporting children and youth with ADHD during future periods of long-term stressors.

The Impact of Stimulant Medications on Blood Pressure and Body Mass Index in Children with Attention Deficit Hyperactivity Disorder

OBJECTIVE

To describe changes in blood pressure (BP) and body mass index (BMI) associated with stimulant medication fills in children.

METHODS

Observational, retrospective matched cohort study of children 6-17.9 years initiating stimulant medication between 7/1/2010-6/30/2017 matched 1:3 by age, race, ethnicity, and sex to children with no stimulant use during this period. All BPs and BMIs recorded during ambulatory visits were identified. Generalized linear models were used to estimate differences in change in systolic BP (SBP), diastolic BP (DBP), and BMI over time.

RESULTS

The 686 children with stimulant prescription fills and 2048 matched controls did not differ by baseline SBP or BMI. The matched control group (30.5% female, mean age 11.2 ± 3.4 years 79.7% white) was more likely to be publicly insured (35% vs. 21%, P < .01). After adjusting for baseline values, over a mean follow-up of 144 days change in SBP or DBP did not differ significantly between patients with stimulant medication fills and matched controls. Stimulant use was associated with a 4.7 percentile decrease in BMI percentile compared to matched controls (95% CI: 3.69, 5.71; P < .01).

CONCLUSIONS

In a pediatric primary care cohort, stimulant prescription fills were associated with marked decreases in BMI but no significant changes in BP over time.

Promoting optimal mental health outcomes for children and youth

While paediatric care providers are often the first point of contact for children or youth experiencing mental health challenges, they may lack the resources (e.g., access to a multidisciplinary team) or training to adequately identify or manage such problems. This joint statement describes the key roles and competencies required to assess and address child and youth mental health problems, and the factors that optimize outcomes in this age group. Evidence-informed guidance on screening for and discussing mental health concerns with young people and families is provided. Preventive and therapeutic interventions with demonstrated efficacy in community care settings are discussed. This foundational statement also focuses on the changes to medical education, health systems, and health policy that are needed to improve clinical practice and advocacy efforts in Canada, including appropriate remuneration models, stepped-care approaches, targeted government funding, and professional training and education.

Impact of a Publicly-Funded Pharmacare Program on Prescription Stimulant use Among Children and Youth: A Population-Based Observational Natural Experiment

OBJECTIVE

Stimulants are first-line pharmacotherapy for individuals with attention-deficit hyperactivity disorder. However, disparities in drug coverage may contribute to inequitable treatment access. In January 2018, the government of Ontario, Canada, implemented a publicly-funded program (OHIP+) providing universal access to medications at no cost to children and youth between the ages of 0 and 24. In April 2019, the program was amended to cover only children and youth without private insurance. We studied whether these policy changes were associated with changes in prescription stimulant dispensing to Ontario children and youth.

METHODS

We conducted a population-based observational natural experiment study of stimulant dispensing to children and youth in Ontario between January 2013 and March 2020. We used interventional autoregressive integrated moving average models to estimate the association between OHIP+ and its subsequent modification with stimulant dispensing trends.

RESULTS

The implementation of OHIP+ was associated with a significant immediate increase in the monthly rate of stimulant dispensing of 53.6 individuals per 100,000 population (95% confidence interval [CI], 36.8 to 70.5 per 100,000) and a 14.2% (95% CI, 12.8% to 15.6%) relative percent increase in stimulant dispensing rates between December 2017 and March 2019 (1198.6 vs. 1368.7 per 100,000 population). The April 2019 OHIP+ program amendment was associated with an increase in monthly stimulant dispensing trends of 10.2 individuals per 100,000 population (95% CI, 5.0 to 15.5), with rates increasing 7.5% (95% CI, 6.2% to 8.7%) between March 2019 and March 2020 (1368.7 vs. 1470.8 per 100,000 population). These associations were most pronounced among males, children and youth living in the highest income neighbourhoods and individuals aged 20 to 24.

CONCLUSION

A publicly-funded pharmacare program was associated with more children and youth being dispensed stimulants.

COGMED working memory training in children with Attention Deficit/Hyperactivity Disorder (ADHD): A feasibility study in Saudi Arabia

Working memory training has been proven effective for improving cognitive functioning in patients with Attention Deficit/Hyperactivity Disorder (ADHD). However, the feasibility of this type of training for children in Saudi Arabia has not been previously explored. We investigated the feasibility of implementing Cogmed Working Memory Training (CWMT) in a sample of 29 Saudi children with ADHD. We found no significant demographic or clinical differences between compliant and noncompliant children. Although compliant children were initially better at following instructions and reported better improvements in working memory and math skills compared to those who did not complete the CWMT, all children who participated in the program showed improvements in performing the CWMT tasks. Most parents found the Cogmed training feasible for their children, were satisfied and keen to continue with the program, and felt the training helped them to address their problems. Most children did not encounter any difficulties in using the software, and many families were, therefore, likely to continue using the techniques from the program. We conclude that CWMT for children with ADHD is feasible in Saudi Arabia. Larger case-controlled studies are needed to thoroughly investigate the effects of CWMT compared to other interventions in Saudi children with ADHD.

Viloxazine for the Treatment of Attention Deficit Hyperactivity Disorder

PURPOSE OF REVIEW

Attention deficit hyperactivity disorder (ADHD) is a widely diagnosed neurodevelopmental disorder giving rise to symptoms of hyperactivity, impulsivity, and inattentiveness that can impair daily functioning. Stimulants, such as methylphenidate and amphetamines, are the mainstay of treatment for ADHD. However, nonstimulant drugs such as viloxazine, atomoxetine, guanfacine, and clonidine are becoming more popular due to minimal adverse effects when compared to stimulants.

RECENT FINDINGS

Viloxazine is a selective norepinephrine reuptake inhibitor (NRI) originally used to treat depression in adults with activity in both the noradrenergic as well as serotonergic pathways. Studies have demonstrated its efficacy for its use in the treatment of ADHD. Unlike stimulants, viloxazine has a decreased chance of substance abuse, drug dependance, and withdrawal symptoms upon the cessation of therapy. Additionally, dopamine levels in the nucleus accumbens after treatment with viloxazine are elevated considerably less in comparison with traditional stimulant ADHD treatments. Viloxazine provides an alternative, nonstimulant approach to treating ADHD.

SUMMARY

Viloxazine is a recently approved, non-stimulant medication functions by inhibiting the uptake of norepinephrine which has been seen to be decreased in patients with ADHD. When patients do not respond to first-line stimulants, cannot tolerate the side effects, or have contraindications to stimulants, viloxazine may be a nonstimulant option offering patients an increasing arsenal of medications to treat ADHD.

The Effects of Neurofeedback on Executive Functioning in Children With ADHD: A Meta-Analysis

OBJECTIVE

Possible beneficial effects of neurofeedback in improving ADHD functional outcomes have been increasingly reported. This meta-analysis aimed to evaluate the relationship between neurofeedback and executive functioning in children with ADHD.

METHODS

PubMed, EMBASE, EBSCO, Web of Science, and Cochrane databases were searched to identify studies reporting the effects of neurofeedback on executive functioning, including response inhibition, sustained attention, and working memory, assessed by neuropsychological tests. Only randomized controlled studies of children aged 5 to 18 years were included using a random-effects model.

RESULTS

Ten studies were included. The effects of neurofeedback were not found on three domains of executive functions. A meta-regression analysis revealed a trend of numbers of neurofeedback sessions positively associated with response inhibition (p = .06).

CONCLUSION

Results did not show the benefits of neurofeedback on executive functions assessed by neuropsychological tests. Future studies should focus on standard neurofeedback protocols, the intensity of intervention, and neuropsychological outcomes.

Stimulant intolerance in children with Angelman syndrome with hyperactivity: a case series

OBJECTIVES

Angelman syndrome is a neurogenetic disorder resulting from the loss of expression of the ubiquitin-protein ligase E3A gene on chromosome 15. Problematic behaviors including attention-deficit/hyperactivity disorder (ADHD) symptoms of hyperactivity, impulsivity and inattention are highly prevalent in Angelman syndrome. The efficacy, safety and tolerability of stimulant medications in children with Angelman syndrome for the treatment of ADHD symptoms have not been previously reported.

METHODS

We describe three boys with Angelman syndrome who were treated with open-label stimulant medications for ADHD symptoms.

RESULTS

Stimulant medications were highly intolerable, and treatment had to be discontinued after limited dosing in all three cases due to marked increases in hyperactivity and impulsivity along with worsened distractibility.

CONCLUSION

The findings of this study suggest that stimulant medications may be ineffective and poorly tolerated in children with Angelman syndrome.

The Efficacy of Physical Activity for Children with Attention Deficit Hyperactivity Disorder: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

This systematic review and meta-analysis assesses the efficacy of regular, moderate to vigorous physical activity (MVPA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents in randomized controlled trials (RCTs).

METHODS

RCTs including children and adolescents with clinically diagnosed ADHD, implementing regular MVPA, and assessing ADHD core-symptoms on a valid rating scale post-intervention (primary outcome) were included. Outcomes were pooled through random-effects meta-analysis. Prospero registration: CRD42019142166.

RESULTS

MVPA had a small effect on total ADHD core symptoms (n = 11; g = -0.33; 95% CI [-0.63; -0.02]; p = .037).

CONCLUSIONS

MVPA could serve as an alternative treatment for ADHD. New RCTs are necessary to increase the understanding of the effect regarding frequency, intensity, type of MVPA interventions, and differential effects on age groups.

Diet modification impact on ADHD outcome

Background

Attention-deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders, affects 5% of children worldwide and characterized by impaired inattention, hyperactivity and impulsivity. One of the risk factors that precipitate ADHD is food. Food affects behavior of children by different ways such as food allergy, food intolerance and gut–microbiota–brain axis. The study aimed to assess effect of diet modification on ADHD outcome and the role of food as a precipitating factor for ADHD symptomatology. The study included 47 children newly diagnosed with ADHD, not receiving medical or behavioral therapy, their ages ranged from 6 to 9 years and their intelligence quotient not below 70 with no associated comorbidities. All participants were subjected to Full history taking, clinical examination, anthropometric measurements, 24 h dietary recall. Dietary analysis and Conner’s parent rating scale-revised short form (CPR-RS) were done before and after diet modification program for 5 weeks.

Results

There was improvement in ADHD symptoms as measured by CPR-RS after 5-weeks of diet modification program. Carbohydrate and protein intake decreased significantly after diet modification program. Energy intake did not show statistical difference while fat intake increased significantly after the diet program. Vitamin A, C, riboflavin, thiamin and iron intakes decreased significantly after diet program but were within the recommended dietary allowance.

Conclusion

Following the Diet modification program, ADHD symptoms were improved as documented by decrease in CPR scores. Diminished carbohydrate and protein intake in diet were positively associated with improvement of ADHD symptoms. Diet modification program succeeded in reducing obesity and then ADHD symptoms.

Practitioner's review: medication for children and adolescents with autism spectrum disorder (ASD) and comorbid conditions

Alleviating the multiple problems of children with autism spectrum disorder (ASD) and its comorbid conditions presents major challenges for the affected children, parents, and therapists. Because of a complex psychopathology, structured therapy and parent training are not always sufficient, especially for those patients with intellectual disability (ID) and multiple comorbidities. Moreover, structured therapy is not available for a large number of patients, and pharmacological support is often needed, especially in those children with additional attention deficit/hyperactivity and oppositional defiant, conduct, and sleep disorders.

Psychopharmacology of Williams syndrome: safety, tolerability, and effectiveness

Introduction: Williams syndrome (WS) is a neurogenetic disorder characterized by a hyper-social personality, intellectual disability, and multiple medical co-morbidities. Psychiatric co-morbidities are also common. Since medical co-morbidities are common in this population, the risk-benefit of the use of psychiatric medications must be carefully considered and monitoring for safety and tolerability is needed.Areas covered: We review the cognitive profile and common medical co-morbidities in WS. We then discuss the common presentations of psychiatric disorders and review the available evidence on the use of psychiatric medications in WS. No prospective psychiatric medication trials have been conducted. We highlight the side effect profile of common psychiatric medications as they pertain to WS.Expert opinion: Psychiatric disorders can have a major effect on the quality of life of individuals with WS. The lack of long-term safety data and high likelihood of medical co-morbidities in WS make the judicious use of psychiatric medications more challenging; however, they can play an important role in decreasing distress and improving functioning. We provide recommendations for first- and second-line classes of medications based on our clinical experience and consideration of adverse effect profiles, as well as safety monitoring parameters at baseline and periodically.

Focusing on ADHD Management

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder in children, and it affects academic performance, personal relationships, and future well-being. Given the prevalence of ADHD, many pediatricians should feel comfortable with the diagnosis and management of this condition. This article aims to improve understanding of ADHD, treatment options including both medication and behavioral interventions, as well as the laws in place to help these patients. [Pediatr Ann. 2020;49(12):e501-e505.].

Approach to diagnosis and management of childhood attention deficit hyperactivity disorder

OBJECTIVE

To provide primary care clinicians with an approach to the diagnosis and management of attention deficit hyperactivity disorder (ADHD) by reviewing and summarizing the relevant practice guidelines and recent evidence from the literature.

SOURCES OF INFORMATION

Published guidelines on the management of ADHD were reviewed. A PubMed search was conducted with the MeSH terms attention deficit disorder and family practice. Results were limited to articles published in English within the past 15 years.

MAIN MESSAGE

Attention deficit hyperactivity disorder is a common neurodevelopmental disorder. Guidelines agree that diagnosis and management of ADHD is appropriate within primary care. Attention deficit hyperactivity disorder is diagnosed by applying the criteria defined within the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, and is supplemented by validated rating scales. Behavioural management is first-line management in all patients, and stimulant medications are first-line management in patients 6 years of age and older. The Canadian ADHD Resource Alliance provides free resources to help clinicians care for patients with ADHD.

CONCLUSION

Most patients with ADHD can be managed by family physicians. It is a chronic condition that requires ongoing follow-up. Attention deficit hyperactivity disorder that is complicated by comorbidities might require referral to a specialist.

Approche diagnostique et de prise en charge du trouble déficitaire de l’attention avec hyperactivité chez l’enfant

Objectif

Proposer aux médecins de première ligne une approche diagnostique et de prise en charge du trouble déficitaire de l’attention avec hyperactivité (TDAH) en examinant et en résumant les lignes directrices pertinentes de pratique clinique et les données récentes relevées dans les publications scientifiques.

Sources d’information

Nous avons examiné les lignes directrices publiées sur la prise en charge du TDAH. Une recherche a été réalisée dans PubMed à l’aide des motsclés anglais attention deficit disorder et family practice . Les résultats étaient limités aux articles publiés en anglais au cours des 15 dernières années.

Message principal

Le trouble déficitaire de l’attention avec hyperactivité est un trouble neurodéveloppemental courant. Les lignes directrices s’entendent pour dire qu’il est approprié de poser un diagnostic et d’entreprendre la prise en charge du TDAH en première ligne. Le trouble déficitaire de l’attention avec hyperactivité est diagnostiqué en appliquant les critères définis dans le Manuel diagnostique et statistique des troubles mentaux, 5e édition, qu’on complète avec les scores aux échelles validées. La prise en charge comportementale est l’intervention de première intention chez tous les patients, et les stimulants sont l’intervention de première intention chez les patients de 6 ans et plus. La Canadian ADHD Resource Alliance fournit gratuitement des ressources aux médecins pour les aider à soigner les patients atteints du TDAH.

Conclusion

La plupart des patients atteints du TDAH peuvent être pris en charge par les médecins de famille. Le TDAH est une affection chronique qui exige un suivi continuel. Les cas de trouble déficitaire de l’attention avec hyperactivité qui sont compliqués par des comorbidités pourraient nécessiter une recommandation à un spécialiste.

Emerging drugs for the treatment of attention-deficit hyperactivity disorder (ADHD)

INTRODUCTION

Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder affecting up to 5.3% of children and 2.5% of adults depending on the country considered. Current pharmacological treatments for ADHD are based on stimulant or non-stimulant medications, targeting dopaminergic and noradrenergic systems in the frontal cortex and dopaminergic system in the basal ganglia. These drugs are effective and safe for the majority of patients, whereas about 20% of treated patients do not tolerate current therapies or experience insufficient efficacy. The adequate treatment of ADHD is necessary to allow a proper social placement and prevent the acquisition of additional, more severe, comorbidities.

AREAS COVERED

We conducted a review of the scientific literature and of unpublished/ongoing clinical trials to summarize the advances made in the last 10 years (2010-2020) for the pharmacological treatment of ADHD. We found many pharmacological mechanisms beyond dopaminergic and noradrenergic ones have been investigated in patients.

EXPERT OPINION

Some emerging drugs for ADHD may be promising as add-on treatment especially in children, amantadine to enhance cognitive functions and tipepidine for hyperactivity/impulsivity. Stand-alone emerging treatments for ADHD include viloxazine and dasotraline, which will soon have more clinical data available to support market access requests.

Attention-Deficit Hyperactivity Disorder, Disruptive Behaviors, and Drug Shortage

Kyle is a 10-year-old boy with Down syndrome and intellectual disability who is being followed up by a developmental behavioral pediatrician for attention-deficit hyperactivity disorder (ADHD) and anxiety. Kyle was initially taking a long-acting liquid formulation of methylphenidate for ADHD and fluoxetine for anxiety. Several months ago, the liquid formulation was on back order, and the methylphenidate formulation was changed to an equal dose of a long-acting capsule. Kyle is not able to swallow pills; therefore, the contents of the capsule were sprinkled onto 1 bite of yogurt each morning. Over the course of the next month, Kyle's behaviors became increasingly difficult. He was not able to tolerate loud or crowded places, and despite a visual schedule and warnings, he would become aggressive toward adults when directed to transition away from preferred activities. Fluoxetine was increased from 0.4 to 0.6 mg/kg/day at that time.One month later, his parents reported that although there may have been slight improvement in Kyle's irritability since the increase in fluoxetine, they felt he was nonetheless more aggressive and less cooperative than his previous baseline. Kyle was returned to the long-acting liquid formulation of methylphenidate at that time, and a follow-up was scheduled 2 weeks later.On return to clinic, his parents reported that Kyle's behaviors had continued to become increasingly difficult. He was described as uncooperative and aggressive at home and school. Kyle was easily upset any time he was not given his way, his behavior was corrected, or he felt that he was not the center of attention. When upset, he would yell, bite, kick, spit, or throw his body to the ground and refuse to move. At 110 pounds, Kyle's parents were no longer able to physically move his body when he dropped to the ground. This was a safety concern for his parents because he had displayed this behavior in the parking lot of a busy shopping area. Because of Kyle's aggressive and unpredictable behavior, parents no longer felt comfortable taking him to public places. Family members who had previously been comfortable staying with Kyle while his parents were out for short periods would no longer stay with him. Overall, the behaviors resulted in parents being unable to go to dinner as a couple or provide individual attention to their other children. The parents described the family as "on edge." How would you approach Kyle's management?

Review of Clinical Outcome Assessments in Pediatric Attention-Deficit/Hyperactivity Disorder

PURPOSE

Various clinical outcome assessments (COAs) are used in clinical research to assess and monitor treatment efficacy in pediatric attention-deficit/hyperactivity disorder (ADHD) trials. It is unclear whether the concepts assessed are those that are important to patients and their caregivers. The concepts measured by commonly used COAs in this population have not been explicitly compared.

METHODS

We conducted reviews of the qualitative literature to extract information on pediatric ADHD-related concepts reported by pediatric patients, parents, and teachers. Using these concepts, we developed a conceptual framework of pediatric ADHD using both the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria and the additional symptoms and behavioral impacts identified in the literature. We searched for COAs that have been used in pediatric ADHD research and mapped their items based on their conceptual underpinning.

RESULTS

Of the 27 COAs found in the empirical literature, 4 COAs assessed only DSM symptoms. The most comprehensive coverage of our conceptual framework was seen in the Swanson, Nolan, and Pelham Rating Scale-DSM-IV (SNAP-IV). Eighteen COAs were used in at least 1 clinical trial: ADHD-Rating Scale-IV (ADHD-RS-IV) was used most often (n=77), followed by SNAP-IV (n=50), Swanson, Kotkin, Agler, M-Flynn, and Pelham Scale (SKAMP; n=31), Weiss Functional Impairment Rating Scale (WFIRS; n=24), and Vanderbilt ADHD Diagnostic Rating Scale (VADRS; n=15).

CONCLUSION

We identified symptoms and behavioral impacts from qualitative studies in pediatric ADHD that are not included in DSM-based criteria. Most COAs used in pediatric ADHD clinical trials measure only those symptoms listed in the DSM. While these COAs can measure symptom severity, they may not assess the full range of symptoms and impacts important to patients and their caregivers. Future research is needed to measure all concepts important to patients and caregivers within ADHD clinical trials.

New Formulations of Stimulants: An Update for Clinicians

In the last 15 years, there has been a marked increase in the number of available stimulant formulations with the emphasis on long-acting formulations, and the introduction of several novel delivery systems such as orally dissolving tablets, chewable tablets, extended-release liquid formulations, transdermal patches, and novel "beaded" technology. All of these formulations involve changes to the pharmaceutical delivery systems of the two existing compounds most commonly employed to treat attention-deficit/hyperactivity disorder (ADHD), amphetamine (AMP) and methylphenidate (MPH). In addition to these new formulations, our knowledge about the individual differences in response has advanced and contributes to a more nuanced approach to treatment. The clinician can now make increasingly informed choices about these formulations and more effectively individualize treatment in a way that had not been possible before. In the absence of reliable biomarkers that can predict individualized response to ADHD treatment, clinical knowledge about differences in MPH and AMP pharmacodynamics, pharmacokinetics, and metabolism can be utilized to personalize treatment and optimize response. Different properties of these new formulations (delivery modality, onset of action, duration of response, safety, and tolerability) will most likely weigh heavily into the clinician's choice of formulation. To manage the broad range of options that are now available, clinicians should familiarize themselves in each of these categories for both stimulant compounds. This review is meant to serve as an update and a guide to newer stimulant formulations and includes a brief review of ADHD and stimulant properties.