Depression, anxiety and obsessive-compulsive symptoms and quality of life in children with attention-deficit hyperactivity disorder (ADHD) during three-month methylphenidate treatment

Translational cognitive systems: focus on attention

Cognitive dysfunction, particularly attentional impairment, is a core feature of many psychiatric disorders, yet is inadequately addressed by current treatments. Development of targeted therapeutics for the remediation of attentional deficits requires knowledge of underlying neurocircuit, cellular, and molecular mechanisms that cannot be directly assayed in the clinic. This level of detail can only be acquired by testing animals in cross-species translatable attentional paradigms, in combination with preclinical neuroscience techniques. The 5-choice continuous performance test (5C-CPT) and rodent continuous performance test (rCPT) represent the current state of the art of preclinical assessment of the most commonly studied subtype of attention: sustained attention, or vigilance. These tasks present animals with continuous streams of target stimuli to which they must respond (attention), in addition to non-target stimuli from which they must withhold responses (behavioral inhibition). The 5C-CPT and rCPT utilize the same measures as gold-standard clinical continuous performance tests and predict clinical efficacy of known pro-attentional drugs. They also engage common brain regions across species, although efforts to definitively establish neurophysiological construct validity are ongoing. The validity of these tasks as translational vigilance assessments enables their use in characterizing the neuropathology underlying attentional deficits of animal models of psychiatric disease, and in determining therapeutic potential of drugs ahead of clinical testing. Here, we briefly review the development and validation of such tests of attentional functioning, as well as the data they have generated pertaining to inattention, disinhibition, and impulsivity in psychiatric disorders.

Methylphenidate for attention problems in epilepsy patients: Safety and efficacy

Children with attention deficit hyperactivity disorder (ADHD) have an increased risk of seizures, and children with epilepsy have an increased prevalence of ADHD. Adults with epilepsy often have varying degrees of attentional dysfunction due to multiple factors, including anti-seizure medications, frequent seizures, interictal discharges, underlying lesions, and psychiatric comorbidities. Currently, there are no approved medications for the treatment of epilepsy-related attentional dysfunction. Methylphenidate (MPH) is a stimulant, FDA-approved for the treatment of ADHD, and often used for ADHD in the setting of pediatric epilepsy. Large database and registry studies indicate safety of MPH in children with ADHD and epilepsy, with no significant effect on seizure frequency. Small single-dose and open-label studies suggest efficacy of MPH in adults with epilepsy-related attention deficits. Methylphenidate represents a possible treatment for attentional dysfunction due to epilepsy, but large, randomized, placebo-controlled, double-blinded studies are needed.

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.

Case Report: Treatment of a Comorbid Attention Deficit Hyperactivity Disorder and Obsessive-Compulsive Disorder With Psychostimulants

Introduction: Attention deficit hyperactivity disorder (ADHD) is a common disease in childhood and adolescence. In about 60% of pediatric patients, the symptoms persist into adulthood. Treatment guidelines for adult ADHD patients suggest multimodal therapy consisting of psychostimulants and psychotherapy. Many adult ADHD patients also suffer from psychiatric comorbidities, among others obsessive-compulsive disorder (OCD). The treatment of the comorbidity of ADHD and OCD remains challenging as the literature is sparse. Moreover, the impact of psychostimulants on obsessive-compulsive symptoms is still unclear. Case Presentation: Here, we report on a 33-year-old patient with an OCD who was unable to achieve sufficient remission under long-term guideline-based treatment for OCD. The re-examination of the psychological symptoms revealed the presence of adult ADHD as a comorbid disorder. The patient has already been treated with paroxetine and quetiapine for the OCD. Due to the newly established diagnosis of ADHD, extended-release methylphenidate (ER MPH) was administered in addition to a serotonin reuptake inhibitor. After a dose of 30 mg ER MPH, the patient reported an improvement in both the ADHD and the obsessive-compulsive symptoms. After discharge, the patient reduced ER MPH without consultation with a physician due to subjectively described side effects. The discontinuation of medication led to a renewed increase in ADHD and obsessive-compulsive symptoms. The readjustment to ER MPH in combination with sertraline and quetiapine thereafter led to a significant improvement in the compulsive symptoms again. Conclusion: The present case shows that in ADHD and comorbid obsessive-compulsive disorder, treatment with psychostimulants can improve the obsessive-compulsive symptoms in addition to the ADHD-specific symptoms. To our knowledge, this is only the second case report describing a treatment with ER MPH for an adult patient with OCD and ADHD comorbidity in the literature. Further research, especially randomized controlled trials, is needed to standardize treatment options.

Mast cell-mediated neuroinflammation may have a role in attention deficit hyperactivity disorder (Review)

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental and behavioral disorder with a serious negative impact on the quality of life from childhood until adulthood, which may cause academic failure, family disharmony and even social unrest. The pathogenesis of ADHD has remained to be fully elucidated, leading to difficulties in the treatment of this disease. Genetic and environmental factors contribute to the risk of ADHD development. Certain studies indicated that ADHD has high comorbidity with allergic and autoimmune diseases, with various patients with ADHD having a high inflammatory status. Increasing evidence indicated that mast cells (MCs) are involved in the pathogenesis of brain inflammation and neuropsychiatric disorders. MCs may cause or aggravate neuroinflammation via the selective release of inflammatory factors, interaction with glial cells and neurons, activation of the hypothalamic-pituitary adrenal axis or disruption of the blood-brain barrier integrity. In the present review, the notion that MC activation may be involved in the occurrence and development of ADHD through a number of ways is discussed based on previously published studies. The association between MCs and ADHD appears to lack sufficient evidence at present and this hypothesis is considered to be worthy of further study, providing a novel perspective for the treatment of ADHD.

Pre-Existing Comorbid Emotional Symptoms Moderate Short-Term Methylphenidate Adverse Effects in a Randomized Trial of Children with Attention-Deficit/Hyperactivity Disorder

Objective: We sought to ascertain whether baseline anxiety/depression and oppositional defiant disorder (ODD) symptoms impacted the experience of short-term methylphenidate (MPH) adverse effects (AEs) in 7- to 11-year-old children with attention-deficit/hyperactivity disorder (ADHD) (n = 171) undergoing a double-blind MPH crossover trial. Method: The Vanderbilt ADHD Diagnostic Parent Rating Scale measured baseline child anxiety/depression and ODD symptomology. The parent-completed Pittsburgh Side Effect Rating Scale assessed the AEs of anxiety, sadness, and irritability at baseline, on placebo, and on three MPH dosages. For each AE, we evaluated comorbidity main effects, dose main effects, and comorbidity × dose interactions. Results: Baseline anxiety/depression × dose and ODD × dose interactions were significant for the AEs of anxiety, sadness, and irritability. Compared with premedication baseline, these AEs attenuated on MPH for children with initially higher comorbidity symptoms, whereas those with initially lower comorbidity symptoms tended toward no change or increasing AE levels. Conclusion: Premedication anxiety/depressive and ODD symptoms may be important predictors of short-term MPH emotional AEs.

Quality of Life Among Children and Adolescents With Tourette Disorder and Comorbid ADHD: A Clinical Controlled Study

OBJECTIVE

To examine (a) the quality of life (QOL) in children with Tourette's disorder (TD) and ADHD (TD + ADHD) compared with ADHD without tics (ADHD alone) and (b) the effects of the severity of tics, ADHD symptoms, comorbid diagnoses, and family functioning on QOL.

METHOD

The assessments included the Kiddie-Schedule for Affective Disorders and Schizophrenia, Yale Global Tic Severity Scale, ADHD Rating Scale, Pediatric Quality of Life Inventory, and Family Assessment Device.

RESULTS

The TD + ADHD group had poorer psychosocial QOL. Agreement between child and parent ratings was higher in the TD + ADHD group, and children reported higher scores than their parents in both groups. Severity of tics and ADHD symptoms had stronger negative associations with parent-reported than child-reported QOL. Significant positive correlations were detected between QOL and family functioning in both groups.

CONCLUSION

Children with TD + ADHD have lower QOL than their peers with ADHD alone. Family functioning seems to affect QOL in both groups.

Cessation of Skin Picking Symptoms With Methylphenidate Treatment in a Child With Comorbid Skin Picking and Attention-Deficit/Hyperactivity Disorder

Skin picking disorder includes behaviors such as picking, scratching, and squeezing of the normal skin in an impulsive, repetitive manner despite the fact that no dermatological condition is detected. Skin picking disorder may also be comorbid in children with attention-deficit/hyperactivity disorder (ADHD) and vice versa. There is a great deal of data regarding the efficacy and safety of methylphenidate (MPH) treatment of ADHD. In this article, we report the cessation of skin picking behaviors in a 10-year-old girl diagnosed as having skin picking disorder and ADHD after modified-release MPH treatment. To our knowledge, this is the first case report that shows the cessation of skin picking behavior after MPH treatment in a child with ADHD.

Combined fluvoxamine and extended-release methylphenidate improved treatment response compared to fluvoxamine alone in patients with treatment-refractory obsessive-compulsive disorder: A randomized double-blind, placebo-controlled study

More effective, tolerable interventions for treatment-refractory obsessive-compulsive disorder (OCD) are needed. Preliminary findings encourage optimism that methylphenidate augmentation may be of benefit in the treatment of OCD. To test modulator methylphenidate (MPH) of extended-release formulations (MPH-ER) a safe and effective add-on therapy for refractory OCD, a pilot randomized, placebo-controlled, double-blind trial was conducted at an outpatient, single-center academic setting. Participants included 44 adults with serotonin reuptake inhibitor (SRI) treatment-refractory OCD and receiving a stable fluvoxamine pharmacotherapy with Yale-Brown Obsessive Compulsive Scale (Y-BOCS) scores higher than 20. Data were analyzed in the intention-to-treat sample. All subjects were randomized into two parallel groups to receive fluvoxamine (250 mg daily) plus MPH-ER (36 mg daily) or fluvoxamine (250 mg daily) plus identical placebo tablets under double-blind conditions and followed for 8 weeks. Forty-four patients (29 [66%] men), with a mean (SD) age of 24.7 (6) years participated; with a mean (SD) duration of episode 5.7 (3) were randomized and forty-one finished the trial. In the intention-to-treat analysis, the improvement in the Y-BOCS total score and Y-BOCS obsession subscale score was more prominent in the fluvoxamine and MPH-ER group compared with those receiving placebo (P < .001). Additionally, cumulative response rates were higher in the MPH-ER vs placebo groups (59% vs 5%; P  < .001). MPH-ER was well tolerated; No subjects dropped out due to side effects. In summary, combined treatment with MPH-ER demonstrated an enhanced clinical rate of response compared to placebo. Further trials should examine MPH-ER efficacy in a larger sample.

Does Parent Stress Predict the Quality of Life of Children With a Diagnosis of ADHD? A Comparison of Parent and Child Perspectives

OBJECTIVE

There are indicators that parental psychological factors may affect how parents evaluate their child's quality of life (QoL) when the child has a health condition. This study examined the impact of parents' perceived stress on parent and child ratings of the QoL of children with ADHD.

METHOD

A cross-sectional sample of 45 matched parent-child dyads completed parallel versions of the KIDSCREEN-27. Children were 8 to 14 years with clinician diagnosed ADHD.

RESULTS

Parents who rated their child's QoL lower than their child had higher perceived stress scores. Parent stress was a unique predictor of child QoL from parent proxy-rated but not child-rated QoL scores.

CONCLUSION

Parents' perceived stress may play an important role in their assessments of their child's QoL, suggesting both parent and child perspectives of QoL should be utilized wherever possible. Interventions that target parent stress may contribute to improvements in the child's QoL.

Baicalin regulates the dopamine system to control the core symptoms of ADHD

We aimed to test the therapeutic effects of baicalin on attention deficit hyperactivity disorder (ADHD) in an animal model and to explain the potential mechanism. We investigated the therapeutic effects and mechanisms of baicalin in a spontaneously hypertensive rat (SHR) model of ADHD depending on the dopamine (DA) deficit theory. In this study, fifty SHRs were randomly divided into five groups: methylphenidate (MPH), baicalin (50 mg/kg, 100 mg/kg, or 150 mg/kg), and saline-treated. Ten Wistar Kyoto (WKY) rats were used as controls. All rats were orally administered the treatment for four weeks. Motor activity, spatial learning and memory ability were assessed with the open-field and Morris water-maze tests. The mRNA and protein levels of tyrosine hydroxylase (TH), vesicular monoamine transporter 2 (VMAT2), synaptosomal-associated protein of molecular mass 25kD (SNAP25) and synataxin 1a in synaptosomes were detected with real-time polymerase chain reaction (PCR) and Western blot. In addition, DA levels were measured in the prefrontal cortex and striatum. The results indicated that both MPH and baicalin at doses of 150 mg/kg and 100 mg/kg significantly decreased the hyperactivity and improved the spatial learning memory deficit in the SHRs and increased the synaptosomal mRNA and protein levels of TH, SNAP25, VMAT2 and synataxin 1a compared with saline treatment. MPH significantly increased DA levels in both the prefrontal cortex (PFC) and striatum, while baicalin significantly increased DA levels only in the striatum. The results of the present study showed that baicalin treatment was effective for controlling the core symptoms of ADHD. Baicalin increased DA levels only in the striatum, which suggested that baicalin may target the striatum. The increased DA levels may partially be attributed to the increased mRNA and protein expression of TH, SNAP25, VMAT2, and syntaxin 1a. Therefore, these results suggested that the pharmacological effects of baicalin were associated with the synthesis, vesicular localization, and release of DA and might be effective in treating ADHD. However, further studies are required to better understand the molecular mechanisms underlying these findings.

Psychiatric comorbid patterns in adults with attention-deficit hyperactivity disorder: Treatment effect and subtypes

Psychiatric comorbidities are common in individuals with attention-deficit/hyperactivity disorder (ADHD). In this study, we sought to evaluate the effects of medication and childhood ADHD subtypes on psychiatric comorbidities among adults with ADHD as compared to healthy adult controls. We assessed 121 drug-naïve adults with ADHD, 93 treated adults with ADHD, and 145 healthy controls (age 18-36 years) using semi-structured psychiatric interviews, intelligence tests, and medical records. Drug-naïve adults with ADHD had more comorbidities than treated adults with ADHD and controls. Childhood ADHD-combined subtype, relative to ADHD-inattentive subtype, was associated with higher risks of comorbidities. Current medication treatment was associate with a higher risk for anxiety disorders, and longer treatment duration was associated with lower risks of mood disorders and sleep disorders. Our results indicate that no medication treatment, short treatment duration, and childhood ADHD-combined subtype are associated with increased risks for psychiatric comorbidities among adults with ADHD.

Attention deficit hyperactivity disorder may be a highly inflammation and immune-associated disease (Review)

Attention deficit hyperactivity disorder (ADHD) is a common behavioral disorder. Previous research has indicated that genetic factors, family education, environment and dietary habits are associated with ADHD. It has been determined that in China many children with ADHD also have allergic rhinitis or asthma. These children are more susceptible to the common cold or upper respiratory infections compared with normal healthy children. Additionally, the common cold or an upper respiratory infection may lead to disease recurrence or worsen the symptoms in these children. Previous studies have determined that ADHD may have a close association with allergic disease. Based on the clinically observed phenomenon and previous studies, it was hypothesized that ADHD is a high inflammation and immune‑associated disease. Therefore, the authors designed clinical and animal experiments to test this hypothesis in the future. Immune system disorders may be a novel part of the etiology of ADHD. The current report may have implications for future clinical practice.

[Effect of baicalin on behavioral characteristics of rats with attention deficit hyperactivity disorder]

OBJECTIVE

To investigate the effect of baicalin on the behavioral characteristics of rats with attention deficit hyperactivity disorder (ADHD), and to provide a basis for further research on baicalin in the treatment of ADHD.

METHODS

A total of 40 SHR rats were randomly divided into model group, methylphenidate hydrochloride (MPH) group, and low-, medium-, and high-dose baicalin groups, with 8 rats in each group. Eight WKY rats were selected as normal control group. The rats in the MPH group (0.07 mg/mL) and the low- (3.33 mg/mL), medium- (6.67 mg/mL), and high-dose (10 mg/mL) baicalin groups were given the corresponding drugs (1.5 mL/100 g) by gavage twice a day, and those in the normal control group and the model group were given an equal volume of normal saline by gavage twice a day. The course of treatment was 4 weeks for all groups. The open field test was performed to observe total moving distance and average moving speed on day 0 of experiment and at 7, 14, 21, and 28 days after gavage and to evaluate the control effects of drugs on hyperactivity and impulsive behavior. The Morris water maze test was used to observe the latency, time spent in the target quadrant, and number of platform crossings and to evaluate the effects of drugs on attention.

RESULTS

The open field test showed that the model group and the drug treatment groups had a significantly longer total moving distance and a significantly higher average moving speed than the normal control group on day 0 (P<0.05). On day 7, the MPH group had significant reductions in total moving distance and average moving speed compared with the model group (P<0.05). On day 14, the MPH group and the high-dose baicalin group had significant reductions in total moving distance and average moving speed compared with the model group (P<0.05). The data on days 21 and 28 showed that compared with the model group, the low-, medium-, and high-dose baicalin groups had gradual reductions in total moving distance and average moving speed (P<0.05). The water maze test showed that compared with the model group, the MPH group and the medium- and high-dose baicalin groups had a significantly longer time spent in the target quadrant (P<0.05), and the MPH group and the high-dose baicalin group had a significantly higher proportion of the moving distance in the target quadrant in total moving distance (P<0.05). The high-dose baicalin group had the highest number of platform crossings among all groups (P<0.05).

CONCLUSIONS

Both baicalin and MPH can regulate the motor ability and learning and memory abilities of SHR rats with ADHD and thus control the core symptoms of ADHD, i.e., hyperactivity, impulsive behavior, and inattention. Baicalin exerts its effect in a dose-dependent manner, and high-dose baicalin has the most significant effect, but compared with MPH, it needs a longer time to play its therapeutic effect.

Methylphenidate effects in the young brain: friend or foe?

Attention deficit hyperactivity disorder (ADHD) is one of the most prevalent neuropsychiatry disorders in children and adolescents, and methylphenidate (MPH) is a first-line stimulant drug available worldwide for its treatment. Despite the proven therapeutic efficacy, concerns have been raised regarding the possible consequences of chronic MPH exposure during childhood and adolescence. Disturbances in the neurodevelopment at these crucial stages are major concerns given the unknown future life consequences. This review is focused on the long-term adverse effects of MPH to the brain biochemistry. Reports conducted with young and/or adolescent animals and studies with humans are reviewed in the context of long-term consequences after early life-exposure. MPH pharmacokinetics is also reviewed as there are differences among laboratory animals and humans that may be relevant to extrapolate the findings. Studies reveal that exposure to MPH in laboratory animals during young and/or adolescent ages can impact the brain, but the outcomes are dependent on MPH dose, treatment period, and animal's age. Importantly, the female sex is largely overlooked in both animal and human studies. Unfortunately, human reports that evaluate adults following adolescent or child exposure to MPH are very scarce. In general, human data indicates that MPH is generally safe, although it can promote several brain changes in early ages. Even so, there is a lack of long course patient evaluation to clearly establish whether MPH-induced changes are friendly or foe to the brain and more human studies are needed to assess the adult brain changes that arise from early MPH treatment.

An update on the safety of psychostimulants for the treatment of attention-deficit/hyperactivity disorder

INTRODUCTION

Methylphenidate is the first-line pharmacological treatment of attention-deficit/hyperactivity disorder (ADHD). Although methylphenidate has a well-established evidence base for treating ADHD, its long-term benefits are unclear. Areas covered: Physical adverse effects, psychiatric adverse events and brain development Expert opinion: Some physical adverse events have been described (e.g. sleep disturbances, growth reduction, loss of appetite), although most are of transient nature. Psychiatric adverse events seem more related to the diagnosis ADHD itself, and not stimulant treatment. Concluding, short-to-mid-term use (i.e., up to 2 years) stimulants are relatively safe, but much less is known about longer-term efficacy and safety of these drugs.

Is there a difference between child self-ratings and parent proxy-ratings of the quality of life of children with a diagnosis of attention-deficit hyperactivity disorder (ADHD)? A systematic review of the literature

There are contemporary indicators that parent proxy-ratings and child self-ratings of a child's quality of life (QoL) are not interchangeable. This review examines dual informant studies to assess parent-child agreement on the QoL of children with attention-deficit/hyperactivity disorder. A systematic search of four major databases (PsycINFO, MEDLINE, EMBASE and Cochrane databases) was completed, and related peer-reviewed journals were hand-searched. Studies which reported quantitative QoL ratings for matched parent and child dyads were screened in accordance with relevant inclusion and exclusion criteria. Key findings were extracted from thirteen relevant studies, which were rated for conformity to the recommendations of an adapted version of the STROBE statement guidelines for observational studies. In the majority of studies reviewed, children rated their QoL more highly than their parents. There was some evidence for greater agreement on the physical health domain than psychosocial domains.

Baicalin may have a therapeutic effect in attention deficit hyperactivity disorder

Baicalin is a flavonoid purified from Scutellaria baicalensis Georgi. It possesses a variety of pharmacological properties, such as anti-inflammatory, antioxidant, antiapoptotic, and neuro-protective properties, and provides protection against cerebral hemorrhage. However, it is seldom considered a therapeutic in mental disorders. Recent studies showed that baicalin protects cerebral functions against ischemia and has sedative and anxiolytic-like effects. Animal experiments showed that it protects dopaminergic neurons in the striatum, hippocampus and substantia nigra. It also has effects such as anti-depressive and anti-epileptic and offers resistance to Parkinson's disease. Attention deficit hyperactivity disorder (ADHD) pathogenesis is closely related to dopamine deficiency. However, the therapeutic effect of baicalin in ADHD has not been studied. We hypothesize that baicalin may protect dopaminergic neurons and increase brain dopamine levels, thus serving as an effective novel treatment for ADHD.

The NK1R-/- mouse phenotype suggests that small body size, with a sex- and diet-dependent excess in body mass and fat, are physical biomarkers for a human endophenotype with vulnerability to attention deficit hyperactivity disorder

The abnormal behaviour of NK1R-/- mice (locomotor hyperactivity, inattentiveness and impulsivity in the 5-Choice Serial Reaction-Time Test) is arguably analogous to that of patients with attention deficit hyperactivity disorder (ADHD). Evidence suggests that small body size and increased body weight are risk factors for ADHD. Here, we compared the body size, body mass and body composition of male and female NK1R-/- mice and their wildtypes that had been fed either standard laboratory chow or a high-fat (45%: 'Western') diet. Male NK1R-/- mice from both cohorts were approximately 7% shorter than wildtypes. A similar trend was evident in females. Male NK1R-/- mice fed the normal diet weighed less than wildtypes but the 'body mass index' ('mBMI': weight (mg)/length (cm)(2)) of female NK1R-/- mice was higher than wildtypes. When given the high-fat diet, the mBMI of both male and female NK1R-/- mice was higher than wildtypes. There were no consistent genotype or sex differences in protein, ash or water content of mice from the two cohorts. However, the fat content of male NK1R-/- mice on the Western diet was considerably (35%) higher than wildtypes and resembled that of females from both genotypes. We conclude that a lack of functional NK1R is associated with small body size but increases vulnerability to an increase in mBMI and fat content, especially in males. This phenotype could also be evident in ADHD patients with polymorphism(s) of the TACR1 gene (the human equivalent of Nk1r).

Perseveration by NK1R-/- ('knockout') mice is blunted by doses of methylphenidate that affect neither other aspects of their cognitive performance nor the behaviour of wild-type mice in the 5-Choice Continuous Performance Test

The underlying cause(s) of abnormalities expressed by patients with attention deficit hyperactivity disorder (ADHD) have yet to be delineated. One factor that has been associated with increased vulnerability to ADHD is polymorphism(s) of TACR1, which is the human equivalent of the rodent NK1 (substance P-preferring) receptor gene (Nk1r). We have reported previously that genetically altered mice, lacking functional NK1R (NK1R-/-), express locomotor hyperactivity, which was blunted by the first-line treatment for ADHD, methylphenidate. Here, we compared the effects of this psychostimulant (3, 10 and 30 mg/kg, intraperitoneally) on the behaviour of NK1R-/- mice and their wild types in the 5-Choice Continuous Performance Test, which emulates procedures used to study attention and response control in ADHD patients. Methylphenidate increased total trials (a measure of 'productivity') completed by wild types, but not by NK1R-/- mice. Conversely, this drug reduced perseveration by NK1R-/- mice, but not by wild types. Other drug-induced changes in key behaviours were not genotype dependent, especially at the highest dose: for example, % omissions (an index of inattentiveness) was increased, whereas % false alarms and % premature responses (measures of impulsivity) declined in both genotypes, indicating reduced overall response. These findings are discussed in the context of the efficacy of methylphenidate in the treatment of ADHD. Moreover, they lead to several testable proposals. First, methylphenidate does not improve attention in a subgroup of ADHD patients with a functional deficit of TACR1. Second, these patients do not express excessive false alarms when compared with other groups of subjects, but they do express excessive perseveration, which would be ameliorated by methylphenidate.

Differences in the performance of NK1R-/- ('knockout') and wildtype mice in the 5‑Choice Continuous Performance Test

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We compared the behaviour of NK1R−/− mice and wildtypes in the 5-Choice Continuous Performance Test.

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NK1R−/− mice did not express excess impulsivity (premature response or false alarms) in this test.

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NK1R−/− mice expressed excessive perseveration, which is common in ADHD.

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The findings point to a behavioural phenotype for ADHD patients with polymorphism of the TACR1 gene.

Mice lacking functional NK1 (substance P-preferring) receptors typically display excessive inattentiveness (omission errors) and impulsivity (premature responses) when compared with wildtypes in the 5-Choice Serial Reaction-Time Test (5-CSRTT). These abnormal behaviours are analogous to those seen in humans suffering from Attention Deficit Hyperactivity Disorder (ADHD). Here we used the 5-Choice Continuous‑Performance Test (5C-CPT) to ascertain whether NK1R−/− mice also display excessive false alarms (an inappropriate response to a ‘no-go’ signal), which is another form of impulsive behaviour. NK1R−/− mice completed more trials than wildtypes, confirming their ability to learn and carry out the task. At the start of Stage 1 of training, but not subsequently, they also scored more premature responses than wildtypes. When the mice were tested for the first time, neither false alarms nor premature responses was higher in NK1R−/− mice than wildtypes but, as in the 5-CSRTT, the latter behaviour was strongly dependent on time of day. NK1R−/− mice expressed excessive perseveration during all stages of the 5C-CPT. This behaviour is thought to reflect compulsive checking, which is common in ADHD patients. These findings point to differences in the 5-CSRTT and 5C-CPT protocols that could be important for distinguishing why the cognitive performance and response control of NK1R−/− mice differs from their wildtypes. The results further lead to the prediction that ADHD patients with polymorphism of the TACR1 gene (the human equivalent of Nk1r) would express more perseveration, but not false alarms, in Continuous Performance Tests when compared with other groups of subjects.

Peer dislike and victimisation in pathways from ADHD symptoms to depression

The following hypotheses were tested in a longitudinal, population-based study: (1) Attention deficit hyperactivity disorder (ADHD) symptoms are associated with peer dislike and victimisation; (2) Peer dislike and victimisation increase the risk for subsequent depression; and (3) The effect of ADHD symptoms on depression is partly mediated through peer dislike and victimisation. Gender differences in mediating pathways through peer dislike and victimisation to depression were additionally explored. The Child Behaviour Checklist (CBCL), Youth Self Report (YSR) and Teacher's Checklist of Pathology (TCP) assessed ADHD symptoms in 728 adolescents. Peer nominations were used to assess peer dislike and victimisation. The Composite International Diagnostic Interview (CIDI) was used to assess depression. Effects of peer dislike, victimisation, and ADHD symptoms on depression were modelled using Cox regression. ADHD symptoms were associated with peer dislike (rs = 0.17, p < 0.001) and victimisation (rs = 0.11, p = 0.001). Dislike, victimisation, and ADHD symptoms increased risk for depression. Risk for depression associated with victimisation and ADHD symptoms reduced with time. Dislike and victimisation mediated 7 % of the effect of ADHD symptoms on depression. Pathways through dislike and victimisation were present in girls but not in boys. Peer dislike and victimisation explain, to a limited extent, the prospective association between ADHD and depression, particularly in girls.

Toward quality care in ADHD: defining the goals of treatment

OBJECTIVE

Therapeutic goals for chronic mental disorders like major depressive disorder (MDD) and schizophrenia have evolved in parallel with the growing medical knowledge about the course and treatment of these disorders. Although the knowledge base regarding the clinical course of ADHD, a chronic psychiatric disorder, has evolved beyond symptomatic improvement and short-term treatment response, long-term goals, such as functional remission, have not yet been clearly defined.

METHOD

A PubMed literature search was conducted to investigate the therapeutic goals of pharmacologic treatment referenced in the published literature from January 1998 through February 2010 using the following commonly used ADHD treatments as keywords: amphetamine, methylphenidate, atomoxetine, lisdexamfetamine, guanfacine, and clonidine. This search was then combined with an additional search that included the following outcome keywords: remission, relapse, remit, response, normal, normalization, recovery, and effectiveness.

RESULTS

Our search identified 102 publications. The majority (88.2% [90/102]) of these contained predefined criteria for treatment response. Predefined criteria for normalization and remission and/or relapse were presented in 4.9% (5/102), 12.7% (13/102), and 3.9% (4/102) of publications, respectively. There was a lack of consistency between the instruments used to measure outcomes as well as the criteria used to define treatment response, normalization, and remission as well as relapse.

CONCLUSION

The therapeutic goals in treating ADHD should address optimal treatment outcomes that go beyond modest reductions of ADHD symptoms to include syndromatic, symptomatic, and functional remission. Future work should focus on reliable and valid tools to measure these outcomes in the clinical trial setting.

A lack of functional NK1 receptors explains most, but not all, abnormal behaviours of NK1R-/- mice(1)

Mice lacking functional neurokinin-1 receptors (NK1R-/-) display abnormal behaviours seen in Attention Deficit Hyperactivity Disorder (hyperactivity, impulsivity and inattentiveness). These abnormalities were evident when comparing the behaviour of separate (inbred: 'Hom') wildtype and NK1R-/- mouse strains. Here, we investigated whether the inbreeding protocol could influence their phenotype by comparing the behaviour of these mice with that of wildtype (NK1R+/+) and NK1R-/- progeny of heterozygous parents ('Het', derived from the same inbred strains). First, we recorded the spontaneous motor activity of the two colonies/genotypes, over 7 days. This continuous monitoring also enabled us to investigate whether the diurnal rhythm in motor activity differs in the two colonies/genotypes. NK1R-/- mice from both colonies were hyperactive compared with their wildtypes and their diurnal rhythm was also disrupted. Next, we evaluated the performance of the four groups of mice in the 5-Choice Serial Reaction-Time Task (5-CSRTT). During training, NK1R-/- mice from both colonies expressed more impulsive and perseverative behaviour than their wildtypes. During testing, only NK1R-/- mice from the Hom colony were more impulsive than their wildtypes, but NK1R-/- mice from both colonies were more perseverative. There were no colony differences in inattentiveness. Moreover, a genotype difference in this measure depended on time of day. We conclude that the hyperactivity, perseveration and, possibly, inattentiveness of NK1R-/- mice is a direct consequence of a lack of functional NK1R. However, the greater impulsivity of NK1R-/- mice depended on an interaction between a functional deficit of NK1R and other (possibly environmental and/or epigenetic) factors.

Self-inserted foreign body and attention-deficit/hyperactivity disorder: evaluated by the Conners' Parent Rating Scales-Revised

OBJECTIVES

We aimed to evaluate the relationship between attention-deficit/hyperactivity disorder (ADHD) and self-inserted foreign bodies (SIFBs) in children by the Conners' Parent Rating Scales-Revised (CPRS-R).

METHODS

Forty-five children (31 males and 14 females) with self-inserted foreign body of ear/nose and 37 healthy children (22 males and 15 females) included into the study. They were all between 3 and 9 years old. The parents filled the socio-demographic information form including age, gender, demographic data, previous medical history of the child and features of the family; and completed the Conners' Parent Rating Scales-Revised (CPRS-R) questionnaire.

RESULTS

In the SIFB group (study), 55.6% of the children were not attending to the school, 31.1% of them were attending to the primary school and 13.3% of them were the pre-school student. These rates were 37.8%, 32.4% and 29.7%, respectively, in the control group. The all CPRS-R subscale values (CG/I, H, ADHD-I, CGI-DI, DSMIV SS-I, DSM-IV SS-HI and DSM-IV SS-T) were significantly higher in the study group than the control group. There was no significant correlation between gender of the children and CPRS-R subscales. Children with lower school success, and having previous psychiatric problems were related to higher CPRS-R values in all subscales. In older children, hyperactivity scores were lower; and in younger children and the children, not going to the school, hyperactivity scores were higher. CPRS-R scores decreased as the child grown.

CONCLUSION

It was concluded that children with ADHD were more likely to have conditions that might damage himself/herself such as self-inserted foreign body or trauma than normal children. To avoid this condition, these families should closely observe the child; and the child should be provided to participate in activities such as group games and activities that contribute to the development of the child. Warning the children properly and close follow-up of the young children are required to prevent this unwanted condition.

Methylphenidate effects on blood serotonin and melatonin levels may help to synchronise biological rhythms in children with ADHD

The neuroendocrine mediators that may contribute to ADHD (Attention deficit and hyperactivity disorder), serotonin and melatonin, are both thought to regulate circadian rhythms, neurological function and stress response. The objective of this study was to determine the effect of the chronic administration of prolonged release methylphenidate (PRMPH) on daily variations in blood serotonin and melatonin and on the excretion of 6-sulphatoxy-melatonin. A total of 179 children (136 males, 42 females) between the ages of 5 and 14 (9.70 ± 2.55) years were enrolled in a controlled quasi-experimental open clinical study. Of the sample, there were 136 Children with ADHD (based on DSM-IV-TR criteria), who were further grouped into subtypes, and the 42 siblings of the participants who did not ADHD patients. Blood samples were taken at 20:00 and 09:00; urine was collected between 21:00 and 09:00. In the ADHD group, the study protocol was repeated after 4.61 ± 2.3 months of treatment. Measurements included melatonin and serotonin by RIA and urine 6-S-aMT by ELISA. Factorial analyses were conducted by STATA 12.0.

RESULTS

ADHD patients showed reduced morning serotonin with a daily profile that was different than the control group due to the predominance of nocturnal concentrations. PRMPH did not result in any significant changes. Melatonin and its daily profile did not differ between controls and the ADHD group with a diurnal rhythm showing higher morning levels that disappear after PRMPH administration. Melatonin was higher in children with predominantly hyperactive-impulsive/conduct disorder subtype. PRMPH resulted in a decrease in 6-S-aMT excretion for both ADHD subtypes.

CONCLUSION

Chronic treatment with prolonged release methylphenidate induces subtle changes in the daily fluctuations and concentrations of both serotonin and melatonin. Improvement in Children's Depression Inventory (CDI) scores was not related to a morning increase in serotonin.

Low quality of life scores in school children with attention deficit-hyperactivity disorder related to anxiety

OBJECTIVE: Attention deficit hyperactivity disorder (ADHD) is an alteration that begins early in infancy and whose cardinal symptoms are inattention, hyperactivity and impulsivity. There are few studies for specific tests to measure Quality of Life (QoL) in children with ADHD. METHODS: We evaluated QoL of 120 children from 7-12 years of age with ADHD and of a group of 98 healthy control children. To measure QoL, we utilized the Questionnaire of Quality of Life for Children in Pictures (AutoQuestionnaire Qualité de Vie Enfant Imagé, AUQUEI). We evaluated anxiety in children by the Children´s Manifest Anxiety Scale-Revisited (CMAS-R). We compared results among groups and employed the calculation of correlation between the AUQUEI questionnaire and the CMAS-R scale. RESULTS: The total average of the AUQUEI questionnaire in children with ADHD was 45.2, while in the control group it was 54.3 (p<0.05). We also observed significant differences between the control group and groups of children with ADHD in the CMAS-R scale. We found significant correlations between AUQUEI questionnaire and CMAS-R scale. CONCLUSION: The main result was to the disclosure that low QoL scores in ADHD children was anxiety-related.

Pharmacological management of treatment-resistant obsessive-compulsive disorder

Once considered rare and resistant to treatment, obsessive-compulsive disorder (OCD) has now emerged as a common, yet often unrecognized, psychiatric condition. Treatment with selective serotonin reuptake inhibitors (SSRIs) is effective in 40-60% of patients with OCD. Management of the remaining 40-60% of patients with treatment-resistant OCD is challenging. We review up-to-date evidence focusing on strategies for treatment-resistant OCD, including increasing the dose of SSRI, switching to another SSRI, augmentation with antipsychotics, and the use of serotonin noradrenaline (norepinephrine) reuptake inhibitors (SNRIs) and monoamine oxidase inhibitors (MAOIs). Finally, we provide a flow chart, which includes nonpharmacological interventions such as cognitive-behavioural therapy, family interventions and physical interventions such as neurosurgery and deep brain stimulation, alongside the pharmacological strategies.

An observational study of once-daily modified-release methylphenidate in ADHD: quality of life, satisfaction with treatment and adherence

Attention deficit hyperactivity disorder (ADHD) impacts significantly on the quality of life (QoL) of patients and their families. Choice of therapy is increasingly influenced by treatment satisfaction and patient preference, with once-daily modified-release methylphenidate (MPH-MR) formulations offering clear benefits compared with immediate-release (IR) dosage forms. The effects of MPH-MR on QoL in ADHD have not been widely investigated and need more clarity in practice. The open-label OBSEER study evaluated the effectiveness and tolerability of Equasym XL(®), a MPH-MR formulation, in routine practice. Children and adolescents (aged 6-17 years) with ADHD and attending school were included if Equasym XL(®) treatment was planned by the treating physician. Physicians, parents and patients completed questionnaires assessing QoL (KINDL; parent, child or adolescent versions), satisfaction with medication, adherence and treatment tolerability at baseline (Visit 1), 1-3 weeks (Visit 2) and 6-12 weeks (Visit 3) over a maximum 3-month observation period. Data from 822 consecutively referred patients were analysed. QoL and medication satisfaction increased from Visit 1 to Visit 3, with both patients and parents rating therapy with Equasym XL(®) as better than previous drug therapy. KINDL total score effect sizes were 0.67 (parents' ratings), 0.52 (children's ratings) and 0.51 (adolescents' ratings; all p < 0.001). All KINDL subscores also increased: both parents and patients had the greatest improvement for school. Adherence to Equasym XL(®) was frequently rated as superior to prior treatment, particularly compared with MPH-IR repeated dosing. Treatment was generally well tolerated; approximately 3% of the patients discontinued treatment due to adverse events. Equasym XL(®) improved QoL compared with prior therapy, and resulted in good medication satisfaction and adherence in drug-naïve and previously treated patients.