The treatment of attention-deficit hyperactivity disorder: an annotated bibliography and critical appraisal of published systematic reviews and metaanalyses

Attention-deficit hyperactivity disorder: should we believe the mass media or peer-reviewed literature?

Bailly's review describes the author's perspectives on the ‘intense controversies' surrounding attention-deficit hyperactivity disorder (ADHD) and its treatment with stimulant medications. Drawing on a range of literature sources, including the UK press, pharmaceutical industry websites and peer-reviewed scientific papers, he questions the validity of ADHD as a concept and disorder, the accuracy and reliability of diagnosis, the use of stimulant medications and the impact of advertising by the pharmaceutical industry. There are, however, additional sources and alternative interpretations.

Parents' Perspectives About Factors Influencing Adherence to Pharmacotherapy for ADHD

OBJECTIVE

The aim of the present study was to explore factors influencing parents' decisions to adhere and persist with ADHD pharmacotherapy in children.

METHOD

Focus groups ( n = 3) were conducted with 16 parents recruited from metropolitan Sydney. Group discussions explored factors impacting on treatment initiation, continuation, and cessation. Focus groups were audio-recorded, transcribed verbatim, and thematically content analyzed.

RESULTS

Parents commenced and continued pharmacotherapy due to its positive impact on their child's behavior. Improvements in the child's academic performance and social interactions encouraged persistence with therapy. Parents elected to cease therapy after their children experienced side effects including appetite suppression, weight loss, and sleep disturbances. Concerns about long-term effects of ADHD medication use including potential for addiction and growth stunting, in addition to the stigma surrounding ADHD also contributed to parents ceasing treatment.

CONCLUSION

The findings highlight a need for the provision of accurate information about ADHD and its treatments to parents to empower their treatment decisions and promote adherence.

Long-Term Efficacy of Methylphenidate Immediate-Release for the Treatment of Childhood ADHD

OBJECTIVE

To evaluate the long-term effects of methylphenidate imediate-release (MPH-IR), and to confirm the efficacy established in previous meta-analyses of short-term studies.

METHOD

Published and unpublished studies in which participants were treated with MPH-IR for 12 weeks or more were searched. Pooled effect sizes from these studies were computed with the DerSimonian and Laird random-effect model. Meta-regression analysis was conducted to estimate covariates associated with treatment effects.

RESULTS

Seven studies were included. Pooled parents ratings for inattention and hyperactivity/impulsivity resulted in standardized mean difference (SMD) = 0.96 (95% confidence interval [CI] = [0.60, 1.32]) and SMD = 1.12 (95% CI = [0.85, 1.39]), respectively; pooled teachers ratings showed SMD = 0.98 (95% CI = [0.09, 1.86]) for inattention and SMD = 1.25 (95% CI = [0.7, 1.81]) for hyperactivity/impulsivity. No evidence of association of any covariates with treatment effect was detected in the meta-regression.

CONCLUSION

MPH-IR is efficacious for childhood ADHD for periods longer than 12 weeks.

A systematic review of meta-analyses of psychosocial treatment for attention-deficit/hyperactivity disorder

The present report synthesizes outcomes across meta-analyses of psychosocial (i.e., non-pharmacological) treatments for ADHD. A total of 12 meta-analyses were identified that met search criteria. The meta-analyses were notable in that there was surprisingly little overlap in studies included across them (range of overlap was 2-46 %). Further, there was considerable diversity across the meta-analyses in terms of the inclusion/exclusion criteria, types of psychosocial treatments reviewed, methodological characteristics, and magnitude of reported effect sizes, making it difficult to aggregate findings across meta-analyses or to investigate moderators of outcome. Effect sizes varied across the outcomes assessed, with meta-analyses reporting positive and significant effect sizes for measures of some areas of child impairment (e.g., social impairment) and small and more variable effect sizes for distal and/or untargeted outcomes (e.g., academic achievement). Results are reviewed in light of the larger literature on psychosocial interventions for ADHD, and specific recommendations for future meta-analyses of psychosocial treatments for ADHD are offered.

Psychosocial treatments for ADHD: a systematic appraisal of the evidence

OBJECTIVE

Children with learning disabilities often experience comorbid ADHD, impacting on the effectiveness of interventions for those children. In addition to pharmacologic intervention, clinicians and educators employ a variety of psychosocial methods to address the behavioral and social issues that arise in children with ADHD, including those with co-occurring learning disabilities. Numerous systematic reviews and meta-analyses have been conducted examining treatment studies using psychosocial interventions for children with ADHD. Because of the importance of such reviews to evidence based clinical and educational practice, it is essential that reviews be conducted with rigorous methodologies to avoid bias in conclusions (Schlosser, Wendt, & Sigafoos, 2007). The purpose of this study was to evaluate the quality of systematic reviews and meta-analyses conducted for psychosocial treatments of ADHD in children.

METHOD

Electronic databases were searched for peer-reviewed, English language studies of psychosocial treatments for ADHD in children up to 18-years-old from 1998 to 2010. Twenty-one studies were identified that met inclusion criteria (13 systematic reviews, 8 meta-analyses). Independent examiners used the quality rating scale proposed by Auperin, Pignon, and Pynard (1997) to rate the characteristics of good systematic reviews and meta-analyses.

RESULTS

Results indicated that certain methodological characteristics were common across trials reviewed, yet shortcomings were common among most reviews, including inadequate descriptions of data extraction methods and lack of quality ratings for trials included in the reviews.

CONCLUSION

Synthesis of findings from the five top-rated reviews and the literature on ADHD suggest that psychosocial treatments contribute to improvements on behavioral and social outcomes. How ADHD and LD interplay in treatment outcomes is largely unexplored.

Do parents of children with attention-deficit/hyperactivity disorder (ADHD) receive adequate information about the disorder and its treatments? A qualitative investigation

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is the most prevalent pediatric neurodevelopmental condition, commonly treated using pharmacological agents such as stimulant medicines. The use of these agents remains contentious, placing parents in a difficult position when deciding to initiate and/or continue their child's treatment. Parents refer to a range of information sources to assist with their treatment decision-making. This qualitative study aimed to investigate 1) parents' ADHD-related knowledge pre- and post-diagnosis, 2) the information sources accessed by parents, 3) whether parents' information needs were met post-diagnosis, and 4) parents' views about strategies to meet their information needs.

METHODS

Three focus groups (n=16 parents), each lasting 1.0-1.5 hours were conducted. Focus groups were audio-recorded and transcribed verbatim. Transcripts were analyzed using the framework method, coded, and categorized into themes.

RESULTS

Generally, parents had limited ADHD-related knowledge prior to their child's diagnosis and perceived prescription medicines indicated for ADHD in a negative context. Parents reported improved knowledge after their child's diagnosis; however, they expressed dissatisfaction with information that they accessed, which was often technical and not tailored to their child's needs. Verbal information sought from health care professionals was viewed to be reliable but generally medicine-focused and not necessarily comprehensive. Parents identified a need for concise, tailored information about ADHD, the medicines used for its treatment, and changes to their child's medication needs with age. They also expressed a desire for increased availability of support groups and tools to assist them in sourcing information from health care professionals during consultations, such as question prompt lists.

CONCLUSION

There are gaps in parents' knowledge about ADHD and its treatment, and an expressed need for tailored and reliable information. Future research needs to focus on providing parents with avenues to access concise, reliable, and relevant information and support in order to empower them to make the best treatment decision for their child.

Parent training interventions for Attention Deficit Hyperactivity Disorder (ADHD) in children aged 5 to 18 years

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterised by high levels of inattention, hyperactivity and impulsivity that are present before the age of seven years, seen in a range of situations, inconsistent with the child's developmental level and causing social or academic impairment. Parent training programmes are psychosocial interventions aimed at training parents in techniques to enable them to manage their children's challenging behaviour.

OBJECTIVES

To determine whether parent training interventions are effective in reducing ADHD symptoms and associated problems in children aged between five and eigtheen years with a diagnosis of ADHD, compared to controls with no parent training intervention.

SEARCH METHODS

We searched the following electronic databases (for all available years until September 2010): CENTRAL (2010, Issue 3), MEDLINE (1950 to 10 September 2010), EMBASE (1980 to 2010 Week 36), CINAHL (1937 to 13 September 2010), PsycINFO (1806 to September Week 1 2010), Dissertation Abstracts International (14 September 2010) and the metaRegister of Controlled Trials (14 September 2010). We contacted experts in the field to ask for details of unpublished or ongoing research.

SELECTION CRITERIA

Randomised (including quasi-randomised) studies comparing parent training with no treatment, a waiting list or treatment as usual (adjunctive or otherwise). We included studies if ADHD was the main focus of the trial and participants were over five years old and had a clinical diagnosis of ADHD or hyperkinetic disorder that was made by a specialist using the operationalised diagnostic criteria of the DSM-III/DSM-IV or ICD-10. We only included trials that reported at least one child outcome.

DATA COLLECTION AND ANALYSIS

Four authors were involved in screening abstracts and at least 2 authors looked independently at each one. We reviewed a total of 12,691 studies and assessed five as eligible for inclusion. We extracted data and assessed the risk of bias in the five included trials. Opportunities for meta-analysis were limited and most data that we have reported are based on single studies.

MAIN RESULTS

We found five studies including 284 participants that met the inclusion criteria, all of which compared parent training with de facto treatment as usual (TAU). One study included a nondirective parent support group as a second control arm.  Four studies targeted children's behaviour problems and one assessed changes in parenting skills. Of the four studies targeting children's behaviour, two focused on behaviour at home and two focused on behaviour at school. The two studies focusing on behaviour at home had different findings: one found no difference between parent training and treatment as usual, whilst the other reported statistically significant results for parent training versus control. The two studies of behaviour at school also had different findings: one study found no difference between groups, whilst the other reported positive results for parent training when ADHD was not comorbid with oppositional defiant disorder. In this latter study, outcomes were better for girls and for children on medication.We assessed the risk of bias in most of the studies as unclear at best and often as high. Information on randomisation and allocation concealment did not appear in any study report. Inevitably, blinding of participants or personnel was impossible for this intervention; likewise, blinding of outcome assessors (who were most often the parents who had delivered the intervention) was impossible.We were only able to conduct meta-analysis for two outcomes: child 'externalising' behaviour (a measure of rulebreaking, oppositional behaviour or aggression) and child 'internalising' behaviour (for example, withdrawal and anxiety). Meta-analysis of three studies (n = 190) providing data on externalising behaviour produced results that fell short of statistical significance (SMD -0.32; 95% CI -0.83 to 0.18, I(2) = 60%). A meta-analysis of two studies (n = 142) for internalising behaviour gave significant results in the parent training groups (SMD -0.48; 95% CI -0.84 to -0.13, I(2) = 9%). Data from a third study likely to have contributed to this outcome were missing, and we have some concerns about selective outcome reporting bias.Individual study results for child behaviour outcomes were mixed. Positive results on an inventory of child behaviour problems were reported for one small study (n = 24) with the caveat that results were only positive when parent training was delivered to individuals and not groups. In another study (n = 62), positive effects (once results were adjusted for demographic and baseline data) were reported for the intervention group on a social skills measure.The study (n = 48) that assessed parenting skill changes compared parent training with a nondirective parent support group. Statistically significant improvements were reported for the parent training group. Two studies (n = 142) provided data on parent stress indices that were suitable for combining in a meta-analysis. The results were significant for the 'child' domain (MD -10.52; 95% CI -20.55 to -0.48) but not the 'parent' domain (MD -7.54; 95% CI -24.38 to 9.30). Results for this outcome from a small study (n = 24) suggested a long-term benefit for mothers who received the intervention at an individual level; in contrast, fathers benefited from short-term group treatment. A fourth study reported change data for within group measures of parental stress and found significant benefits in only one of the two active parent training group arms (P ≤ 0.01).No study reported data for academic achievement, adverse events or parental understanding of ADHD.

AUTHORS' CONCLUSIONS

Parent training may have a positive effect on the behaviour of children with ADHD. It may also reduce parental stress and enhance parental confidence. However, the poor methodological quality of the included studies increases the risk of bias in the results. Data concerning ADHD-specific behaviour are ambiguous. For many important outcomes, including school achievement and adverse effects, data are lacking.Evidence from this review is not strong enough to form a basis for clinical practice guidelines. Future research should ensure better reporting of the study procedures and results.

The EU paediatric regulation: effects on paediatric psychopharmacology in Europe

Child and adolescent psychiatry is a relatively young field and the recognition, classification, and treatment of disorders in children and adolescents lag behind those in adults. In recent years there is an increasing awareness of the differences between children and adults in psychopathology and pharmacology. Related to this new paediatric regulations have been introduced. This article reviews the regulatory and legislative measures that were adopted in the EU in 2007 and the subsequent impact of these measures on the field of paediatric psychopharmacology. The consequences of the paediatric regulation in the EU are reflected in several domains: regulatory, research aimed at drug development and clinical practices. In the regulatory domain, the consequences include: new paediatric indications, inclusion of special (class) warnings, specification of dose regimens, and information on safety specific to children and adolescents, and development of new medicinal formulations. The paediatric regulation leads to timely development of paediatric friendly formulations and better quality of the clinical evidence. In clinical practices, an increased awareness of the uniqueness of paediatric pharmacology is emerging among medical professionals, and subsequent improvement of medical care (i.e. correct doses, appropriate formulation, monitoring for expected adverse events). In addition, clinical guidelines will have to be revised more frequently in order to integrate the recently acquired knowledge. The new regulations stimulate transparency and discussions between academia, pharmaceutical industry, and regulators. The purpose is to optimize clinical research and obtain evidence for paediatric psychopharmacology, thereby providing adequate support for treatment.

Long-term efficacy of methylphenidate in enhancing attention regulation, social skills, and academic abilities of childhood cancer survivors

PURPOSE

Methylphenidate (MPH) ameliorates attention problems experienced by some cancer survivors in the short term, but its long-term efficacy is unproven.

PATIENTS AND METHODS

This study investigates the long-term effectiveness of maintenance doses of MPH in survivors of childhood brain tumors (n = 35) and acute lymphoblastic leukemia (n = 33) participating in a 12-month MPH trial. Measures of attention (Conners' Continuous Performance Test [CPT], Conners' Rating Scales [CRS]), academic abilities (Wechsler Individual Achievement Test [WIAT]), social skills (Social Skills Rating System [SSRS]), and behavioral problems (Child Behavior Checklist [CBCL]) were administered at premedication baseline and at the end of the MPH trial while on medication. A cancer control group composed of patients who were not administered MPH (brain tumor = 31 and acute lymphoblastic leukemia = 23) was assessed on the same measures 12 [corrected] months apart.

RESULTS

For the MPH group, repeated measures analysis of variance revealed significant improvement in performance on a measure of sustained attention (CPT indices, P < .05); parent, teacher, and self-report ratings of attention (CRS indices, P < .05), and parent ratings of social skills or behavioral problems (SSRS and CBCL indices; P < .05). In contrast, the cancer control group only showed improvement on parent ratings of attention (Conners' Parent Rating Scale indices; P < .05) and social skills (SSRS and CBCL indices; P < .05). There was no significant improvement on the academic measure (WIAT) in either group.

CONCLUSION

Attention and behavioral benefits of MPH for childhood cancer survivors are maintained across settings over the course of a year. Although academic gains were not identified, MPH may offer benefits in academic areas not assessed.

Second opinions improve ADHD prescribing in a medicaid-insured community population

OBJECTIVE

The appropriate use of psychotropic medications in youths is an important public health concern. In this article, we describe a review process developed to monitor the use of stimulants and atomoxetine for attention-deficit/hyperactivity syndrome (ADHD) in youths receiving fee-for-service Medicaid services.

METHOD

Washington State Medicaid developed threshold safety parameters for ADHD medications through a process involving the community. A second opinion was mandated when safety thresholds based on dose, combination therapies, or age was exceeded. Use and cost were compared 2 years before and after the program began.

RESULTS

From May 2006 to April 2008, 5.35% of ADHD prescriptions exceeded safety thresholds, resulting in 1,046 second-opinion reviews. Of those, 538 (51.4%) resulted in a prescription adjustment. Adjustments were made to primary care physician (52%), psychiatrist (50%), nurse practitioner (54%), and physician assistant-written (51%) prescriptions. When the preperiod and postperiod were compared, second opinions reduced ADHD medication at high doses (53%), in combinations (44%), and for patients 5 years of age and younger (23%). The review process resulted in a savings of $1.2 million, with 538 fewer patients exceeding safety thresholds. This was a 10:1 return over administrative costs; however, the overall Medicaid expenditures for ADHD medication still increased because of higher unit costs and the preferential use by clinicians of newer brands entering the market.

CONCLUSIONS

A statewide second-opinion process reduced outlier ADHD medication prescription practices and was cost-effective. Suggestions for process and quality improvements in prescribing to children diagnosed with ADHD are discussed.

Parent training interventions for attention deficit hyperactivity disorder

This is the protocol for a review and there is no abstract. The objectives are as follows: To determine whether parent-training interventions are effective in reducing ADHD symptoms and associated problems (e.g. disruptive behaviour disorders or child-specific impairments such as learning difficulties) in children and young people aged 5-18 with ADHD, compared to controls with no parent-training interventions.

[Efficacy of psychiatric and psychotherapeutic interventions in children and adolescents with psychiatric disorders--a systematic evaluation of meta-analyses and reviews. Part II: ADHD and conduct disorders]

OBJECTIVE

In recent years, a large and growing body of research on the effectiveness of treatments for psychiatric disorders in childhood and adolescence has been published; however the large number makes it difficult to get an overview on the current status of research. The aim of this article is to systematically review the existing meta-analyses and reviews disorders on the four most frequent childhood and adolescent psychiatric disorders (anxiety disorder, depression, ADHD, conduct disorder) and to present an up-to-date summary on the effects of treatment for those disorders.

METHODS

This article is based on a systematic literature search, which produced 112 meta-analyses and reviews on the efficacy of psychological and psychiatric interventions in childhood and adolescence published between 2000 and 2007. The articles resulting from the literature search were evaluated according to clearly defined criteria. Presentation of the results follows a dichotomous classification (internalizing vs. externalizing disorders), with Part II of this article reporting the results on ADHD and conduct disorders.

RESULTS

The majority of reviews published between 2000 and 2007 focuses on the treatment of depressive disorders and ADHD. Only for ADHD is the use of medication (stimulants) considered to be the most efficacious treatment option available. For the remaining three disorders, psychotherapy is recommended as the most effective treatment of choice. A combination of psychological and pharmacological treatments is an important option in ADHD and depressive disorders. Considering the efficacy, treatments for ADHD and anxiety disorders produce higher effect-sizes than do interventions for depressive and conduct disorders. For all disorders, there are several desiderata (content and methodological aspects) to be incorporated into future research.

CONCLUSIONS

Empirically supported treatment recommendations can be derived for anxiety disorders, depressive disorders, ADHD and conduct disorders. Finally, important implications for research and practice are discussed.

Adverse effects of pharmacotherapies for attention-deficit hyperactivity disorder: epidemiology, prevention and management

Medication for the treatment of attention-deficit hyperactivity disorder (ADHD) is in widespread use globally. There is considerable data suggesting that overall, the adverse effect burden from this use is dose dependent and is in the mild to moderate category, but few comprehensive reviews exist of the epidemiology of adverse effects alone. This review provides a general and systems-specific summary of the scientific literature regarding adverse effect data for the drugs in general use for the treatment of ADHD. Although several areas lack definitive data, current evidence suggests that, for the majority of those treated for ADHD, the medications currently available pose little in the way of risk of significant harm. Epidemiological data suggest a low incidence of serious adverse effects, whilst the less serious adverse effects, such as insomnia and anorexia, are relatively common. Also, some specific areas of study suggest lower risks of harm than previously thought, e.g. tic disorders and seizures. However, pre-existing conditions and other interindividual differences may raise the risk of harmful adverse effects, which adds emphasis to the need for careful pretreatment assessment and monitoring. Potential but unlikely long-term treatment effects need to be investigated as carefully as possible, particularly with regard to cardiac sequelae and carcinogenesis. There are both overlaps and differences between the adverse effects of stimulants and nonstimulants, such as atomoxetine. For example, the latter shares the stimulant group's potential for changing cardiovascular parameters, but may not cause insomnia.

A theoretical approach to medication adherence for children and youth with psychiatric disorders

This article provides a theoretical review of treatment adherence for children and youth with psychiatric disorders where pharmacological agents are first-line interventions. Four empirically based models of health behavior are reviewed and applied to the sparse literature about medication adherence for children with attention-deficit/hyperactivity disorder and young people with first-episode psychosis. Three qualitative studies of medication use are summarized, and details from the first-person narratives are used to illustrate the theoretical models. These studies indicate, when taken together, that the clinical approach to addressing poor medication adherence in children and youth with psychiatric disorders should be guided by more than one theoretical model. Mental health experts should clarify beliefs, address misconceptions, and support exploration of alternative treatment options unless contraindicated. Recognizing the larger context of the family, allowing time for parents and children to change their attitudes, and offering opportunities for easy access to medication in the future are important ways of respecting patient preferences, while steering them toward best-evidence interventions. Future research using qualitative methods of inquiry to investigate parent, child, and youth experiences of mental health interventions should identify effective ways to improve treatment adherence.

Efficacy of methylphenidate, psychosocial treatments and their combination in school-aged children with ADHD: a meta-analysis

INTRODUCTION

This meta-analysis compares effect-sizes of methylphenidate and psychosocial treatments and their combination on ADHD, concurrent oppositional, conduct symptoms, social behaviors and academic functioning.

METHOD

Several databases (PubMed, PsycInfo, ISI Web of Science) were searched for articles published between 1985 and September 2006. Inclusion criteria were: a diagnosis of ADHD; age from 6-12 years; a randomized controlled treatment design; efficacy established with parent and teacher rating scales; psychosocial treatments used were described as behavioral or cognitive-behavioral; the methylphenidate treatment was short-acting; and finally, treatment was conducted in a clinical setting.

RESULTS

ADHD outcomes showed large mean weighted effect-sizes for both methylphenidate and combined treatments, psychosocial treatments had a moderate mean weighted effect-size; a similar pattern emerged for oppositional and conducted behavior symptoms. Social behavior outcomes showed comparable moderate mean weighted effect-sizes for all treatments, while on academic functioning, all treatments had low mean weighted effect-sizes. There was no correlation between duration of psychosocial treatment and effect-size.

CONCLUSIONS

Both methylphenidate and psychosocial treatments are effective in reducing ADHD symptoms. However, psychosocial treatment yields smaller effects than both other treatment conditions. Psychosocial treatment has no additional value to methylphenidate for the reduction of ADHD and teacher rated ODD symptoms. However, for social behavior and parent rated ODD the three treatments were equally effective. For improvement of academic functioning no treatment was effective.

Psychosocial treatments for children with attention deficit/hyperactivity disorder

This article reviews studies examining the efficacy of behavioral interventions for the treatment of attention-deficit/hyperactivity disorder (ADHD). A specific emphasis is placed on evidence-based interventions that include parent training, classroom, academic, and peer interventions. Results indicate that school-aged children respond to behavioral interventions when they are appropriately implemented both at home and in the classroom setting. Combined treatments (behavioral management and stimulant medication) represent the gold standard in ADHD treatment and are often recommended as the first-line treatment option due to the many problems faced by children with ADHD. Diversity issues, although an important consideration in the treatment of ADHD, continue to remain an understudied area. Recommendations for future research are made pertaining to treatment sequencing with regard to behavior management as well as for subgroups of ADHD children who may respond best to specific treatments.

Is OPTAx useful for monitoring the effect of stimulants on hyperactivity and inattention? A brief report

PURPOSE

The purpose of this study was to investigate whether OPTAx, an objective measurement of hyperactivity, impulsivity and inattention can be used to measure the positive clinical effect of stimulants found in children with hyperkinetic disorder (HKD) or attention deficit disorder without hyperactivity.

METHOD

A total of 22 boys and one girl, with ages ranging between 7-12 years, diagnosed with HKD or attention deficit disorder without hyperactivity and receiving treatment with stimulants were tested with OPTAx, with and without stimulants. The main parameters investigated were: displacement, area, accuracy, variability, errors of commission and errors of omission.

RESULTS

OPTAx showed a significant improvement on all parameters during stimulant treatment compared with no treatment. The improvement measured by OPTAx was supported by clinical assessment, which found that 95% of the children improved much or very much on the Clinical Global Assessment Scale during stimulant treatment.

CONCLUSIONS

The objective parameters of the OPTAx reflected the clinical improvement found in children with HKD or attention deficit disorder without hyperactivity during stimulant treatment. This suggests a greater role for objective measurements such as OPTAx in daily clinical practise.

Correlates of methylphenidate use in Canadian children: a cross-sectional study

OBJECTIVES

This study aimed to estimate the prevalence of methylphenidate (MPH) use among Canadian children aged 2 to 11 years, from 1994-1995 to 1998-1999 and to identify sociodemographic, child, and parent-family correlates are identified.

METHODS

Cross-sectional data collections from the National Longitudinal Survey of Children and Youth (NLSCY) for 1994-1995, 1996-1997, and 1998-1999 were used and samples weighted up to population levels (n=17,814 in 1994-1995, 13,575 in 1996-1997, and 18,980 in 1998-1999). Logistic regression identified correlates of parent-reported MPH use in each time period.

RESULTS

MPH use by Canadian children increased from 1.33% (95% confidence interval [CI], 1.17% to 1.50%) in 1994-1995 to 1.60% (95% CI, 1.42% to 1.78%) in 1998-1999. Use among school children aged 6 to 11 years increased from 1.94% (95% CI, 1.68% to 2.20%) in 1994-1995 to 2.42% (95% CI, 2.14% to 2.71%) in 1998-1999. Use of MPH increased among girls, from 0.52% (95% CI, 0.32% to 0.67%) in 1994-1995 to 0.97% (95% CI, 0.77% to 1.17%) in 1998-1999. For a child with parent-reported hyperactivity, the odds ratios for using MPH were 6.30 (95% CI, 4.94 to 8.90) in 1994-1995 and 12.54 (95% CI, 9.74 to 16.16) in 1998-1999. Age 6 to 11 years, male sex, and absence of parental alcohol use were significant correlates of MPH use in all time periods. Parental smoking correlated with MPH use in 1994-1995 and in 1998-1999.

CONCLUSIONS

Less than 2% of Canadian children used MPH between 1994 and 1999. Some increase in use occurred among school-aged children and girls. Parent-reported hyperactivity was the most important correlate of MPH use.

Order bias in estimates of willingness to pay for drugs to treat attention-deficit/hyperactivity disorder

This study investigated the presence of order bias in contingent valuation studies. We compared the willingness to pay (WTP) for an improved drug for attention-deficit/hyperactivity disorder with that for the standard drug and examined whether the order in which the drugs are presented influences the results obtained. A pretested questionnaire was administered to 114 university students. WTP was elicited using the payment card method. A split sample was used to test order bias. The average WTP per month was euro 57.34 for the standard drug and euro 81.95 for the new drug. The results show that WTP for a new drug varies according to the order in which the drugs are presented. Respondents stated a higher WTP for the new drug if the standard therapy was presented first. This may be due to order bias, evidence of which has also been found in other studies and which is considered to be a limitation of the method. Finally, the use of marginal WTP is suggested as a solution.

Comparative efficacy of once-a-day extended-release methylphenidate, two-times-daily immediate-release methylphenidate, and placebo in a laboratory school setting

BACKGROUND

Given the dosing limitations of methylphenidate short-acting preparations in treating ADHD, galenics with longer release of the substance were developed mainly to avoid drug intake during school hours.

OBJECTIVES

This investigation was conducted to assess the efficacy and the duration of action of a new extended-release formulation of methylphenidate (Medikinet retard) as a once-daily treatment for children with attention-deficit hyperactivity disorder (ADHD).

METHOD

This was a randomized, double-blind, crossover multicentre study with three treatment conditions: once-daily extended-release methylphenidate, twice-daily immediate-release methylphenidate and placebo given to 79 children (8-14 years old) with ADHD. Daily assessments in an analogue classroom setting included blind ratings of attention and deportment and a performance measure (math test) obtained 5 times over an 8-hour period. Secondary measures included an ADHD rating scale, based on DSMIV/ ICD-10 separately rated for the morning and the afternoon.

RESULTS

Both active treatment conditions displayed significant time course effects and were superior to placebo in improving all efficacy measures. Once a day extended-release methylphenidate was not different from the same dose of twice daily immediate-release methylphenidate.

CONCLUSIONS

These data provide support for the benefit of this novel, once-daily methylphenidate preparation in the treatment of ADHD. The longer duration of action of Medikinet Retard has the potential to simplify psychostimulant treatment, thus reducing dose diversion and eliminating the need for in-school administration.

Effectiveness of an adaptive multimodal treatment in children with Attention-Deficit Hyperactivity Disorder -- global outcome

BACKGROUND

The meaning of different components within a multimodal treatment of ADHD remains to be further clarified.

OBJECTIVE

To evaluate the effectiveness of behaviour therapy and drug treatment within an adaptive and individually tailored multimodal treatment for children with ADHD.

METHOD

After an initial psychoeducation n = 75 school-children aged 6-10 years with a diagnosis of ADHD/HKD were assigned to either behaviour therapy (including continued psychoeducation) or medical management with methylphenidate plus psychoeducation. Depending on the effectiveness, the treatment was either terminated (if totally effective) with long-term aftercare and continuation of medication if needed, or (if partially effective) the other treatment component was added (combined treatment), or (if ineffective) the treatment components were replaced. Thus a treatment rationale was applied which resulted in an adaptive and individually tailored therapy -- similar to a strategy that may be useful in clinical practice.

RESULTS

Of the children who started with behaviour therapy after initial psychoeducation 26% received a combined treatment in later treatment stages. In most of the cases (82%) with initial medical management, behaviour therapy was added. ADHD symptoms, individually defined behaviour problems and comorbid symptoms were significantly reduced during the course of treatment. On core measures large pre-post effect sizes were found. On teacher ratings combined treatment was more effective than behaviour therapy.

CONCLUSIONS

Both, behaviour therapy and combined treatment are effective interventions within an adaptive and individually tailored multimodal treatment strategy.

Die Wirksamkeit von Stimulanzien-Retardpräparaten bei Kindern und Jugendlichen mit ADHD - eine systematische Übersicht

Zusammenfassung: Stimulanzien sind das Mittel der Wahl zur pharmakologischen Behandlung einer Aufmerksamkeits-/Hyperaktivitätsstörung. Jedoch ist die Wirkdauer von schnell freisetzenden Präparaten oft nicht ausreichend. Mittlerweile wurden verschiedene retardierte Methylphenidat-, aber auch Amphetaminformen entwickelt, um die Probleme einer mehrfach täglichen Einnahme zu minimieren. Der Artikel stellt die klinischen Studien zu Wirksamkeit, Wirkdauer und Nebenwirkungsprofil verschiedener Stimulanzienformen dar. In der klinischen Anwendung sind die neuen Retard-Produkte wirkungsvolle Alternativen. Eine kontinuierliche mehrstufige Freisetzung des Wirkstoffs über den Tag verteilt nach einmaliger Medikamentengabe bietet Vorteile. Allerdings müssen Nebenwirkungen durch die verlängerte Wirkungsdauer genau beobachtet werden. Eine genauere Anpassung an die jeweiligen Erfordernisse der verschiedenen Tagesabschnitte und -bedürfnisse der Kinder und Jugendlichen ist schwierig. Die Erprobung von Titrierungsschemata unter Einbeziehung von schnell und verzögert freisetzenden Präparaten bleibt eine Aufgabe zukünftiger Forschung.

Lassen sich hyperkinetische Auffälligkeiten am Nachmittag durch eine Morgengabe von Methylphenidat Retard vermindern?

Zusammenfassung: Fragestellung: Neuere galenische Zubereitungen erlauben es, langzeitwirksame Methylphenidatpräparate mit einer zweistufigen Freisetzungsdynamik herzustellen und so durch eine morgendliche Einmalgabe der Unterstützung von Schulkindern mit Aufmerksamkeitsdefizit-/Hyperaktitivätsstörung (ADHS) besser gerecht zu werden. Die Studie analysiert die Wirksamkeit von Medikinet®-Retard, einem neuen retardierten Methylphenidat-Präparat, bei der Veränderung der ADHS-Symptomatik am Nachmittag nach Einschätzung der Lehrer und Eltern. An dieser Stelle soll insbesondere auf Effekte im Urteil der Eltern eingegangen werden. Methode: In einer placebo-kontrollierten, randomisierten, doppelblinden, multizentrischen Studie wurden 85 durchschnittlich intelligente Kinder (Alter 6-16 Jahre, Diagnose: ADHS) untersucht. Die Dauer der Behandlung mit Medikinet®-Retard (n = 43) bzw. Placebo (n = 42) betrug 4 Wochen mit wöchentlichen Visiten. Eine wöchentliche Titrierung erfolgte bis maximal 60 mg in Abhängigkeit vom Körpergewicht und dem Verlauf der Symptomatik. Kriterium für die Verminderung der Symptomatik in der Familie war die wöchentliche Einschätzung der Lehrer und Eltern im Fremdbeurteilungsbogen für Hyperkinetische Störungen (FBB-HKS). Ergebnisse: In der ADHS-Symptomatik, erfasst über den FBB-HKS, ließen sich signifikante Medikamentenwirkungen nachweisen. Die Effektstärke der Veränderungen lag bei d = 1.2 (Gesamtkennwert). Die Effekte ließen sich für Aufmerksamkeitsstörung, Hyperaktivität und Impulsivität auf den entsprechenden Subskalen belegen. Die Wirksamkeit von Medikinet®-Retard wurde von den Eltern durchschnittlich als gut eingeschätzt. Die Reponderrate war in der Verumgruppe viermal höher. Die Korrelationen der Veränderungswerte im Elternurteil mit den Veränderungswerten im Lehrerurteil lagen im mittleren Bereich. Schlussfolgerung: Mit dieser Studie liegen im deutschsprachigen Raum erstmals Daten für eine erfolgreiche Symptomreduktion und gute Wirksamkeit im Elternurteil eines langzeitwirksamen Methylphenidatpräparates (Medikinet®-Retard) vor. Die zweistufige Freisetzungsdynamik erlaubt eine praxistaugliche morgendliche Einmalgabe. Es zeigen sich Wirkungen bis in den Nachmittag.

Comparative pharmacodynamics and plasma concentrations of d-threo-methylphenidate hydrochloride after single doses of d-threo-methylphenidate hydrochloride and d,l-threo-methylphenidate hydrochloride in a double-blind, placebo-controlled, crossover laboratory school study in children with attention-deficit/hyperactivity disorder

OBJECTIVE

Methylphenidate has four optical isomers due to two asymmetries (erythro-threo and dextro-levo). The initial commercial formulation eliminated the erythro isomer, but the dextro-levo asymmetry was racemic, with equal amounts of d and l-threo isomers (d,l-MPH). Previous work has suggested that the d-threo isomer methylphenidate (d-MPH) rather than the l-threo isomer (l-MPH) is responsible for the clinical effects in children with attention-deficit/hyperactivity disorder (ADHD). This study compared the efficacy of acute equimolar doses of d-MPH and dl-MPH in reducing ADHD symptoms over an 8-hour period in a laboratory school setting and investigated the relationship of efficacy to plasma levels of MPH.

METHOD

Thirty-two children with ADHD enrolled in this double-blind, placebo-controlled, crossover study, and 31 completed the study. On seven separate occasions separated by at least 6 days, the children received a single morning dose of d-MPH (2.5, 5, or 10 mg), d,l-MPH (5, 10, or 20 mg), or placebo and then were observed in a laboratory classroom setting for 8 hours. At specified intervals, blinded observers rated behavior, and the children performed a computerized math test. The plasma levels of MPH were related to the response to study medication. The safety profiles of the two formulations were compared.

RESULTS

For both formulations, the responses to both MPH preparations were dose related, the plasma concentrations of l-MPH were negligible and of d-MPH were indistinguishable, and clinical efficacy was highly correlated with plasma concentrations of d-MPH. The efficacy of the d-isomer was equivalent to the racemic preparation in reducing ADHD symptoms and increasing academic productivity.

CONCLUSIONS

The efficacy of MPH resides in the d-isomer. The elimination of the l-isomer does not diminish the efficacy of an acute dose of methylphenidate.

Use of stimulants for attention deficit hyperactivity disorder: FOR

Definitive diagnosis of attention deficit hyperactivity disorder is complex. David Coghill believes the condition is undertreated, but Harvey Markovitch argues that current uncertainties about diagnosis and treatment mean doctors should be cautious

Cost-effectiveness of dexamphetamine and methylphenidate for the treatment of childhood attention deficit hyperactivity disorder

OBJECTIVE

To analyze from a health sector perspective the cost-effectiveness of dexamphetamine (DEX) and methylphenidate (MPH) interventions to treat childhood attention deficit hyperactivity disorder (ADHD), compared to current practice.

METHOD

Children eligible for the interventions are those aged between 4 and 17 years in 2000, who had ADHD and were seeking care for emotional or behavioural problems, but were not receiving stimulant medication. To determine health benefit, a meta-analysis of randomized controlled trials was performed for DEX and MPH, and the effect sizes were translated into utility values. An assessment on second stage filter criteria ("equity", "strength of evidence", "feasibility" and "acceptability to stakeholders") is also undertaken to incorporate additional factors that impact on resource allocation decisions. Simulation modelling techniques are used to present a 95% uncertainty interval (UI) around the incremental cost-effectiveness ratio (ICER), which is calculated in cost (in A$) per DALY averted.

RESULTS

The ICER for DEX is A$4100/DALY saved (95% UI: negative to A$14 000) and for MPH is A$15 000/DALY saved (95% UI: A$9100-22 000). DEX is more costly than MPH for the government, but much less costly for the patient.

CONCLUSIONS

MPH and DEX are cost-effective interventions for childhood ADHD. DEX is more cost-effective than MPH, although if MPH were listed at a lower price on the Pharmaceutical Benefits Scheme it would become more cost-effective. Increased uptake of stimulants for ADHD would require policy change. However, the medication of children and wider availability of stimulants may concern parents and the community.

Stimulant treatment over five years: adherence, effectiveness, and adverse effects

OBJECTIVE

To evaluate the impact of adherence and medication status on effectiveness and adverse effects of stimulant use in children with attention-deficit/hyperactivity disorder (ADHD) over 5 years.

METHOD

Seventy-nine of 91 participants in a 12-month randomized controlled trial of methylphenidate and parent groups enrolled in a follow-up study. Adherence to stimulants, treatment response, and adverse effects were evaluated annually for 5 years. Changes in teacher-reported symptoms and parent-reported adverse effects were compared at 2, 3, 4, and 5 years for 3 groups: adherents, nonadherents on medication, or nonadherents off medication. Controlling for age, gender, and baseline severity, adherence status and medication status were evaluated as correlates of teacher-reported ADHD symptom scores at each year using multiple regression analyses.

RESULTS

At 2 years, adherents (n = 41) showed greater improvement in teacher-reported symptoms than those off medication (n = 16) and equivalent response to nonadherents on stimulants (n = 16) (p =.02). At 5 years, adherents (n = 16) showed greater improvement in teacher-reported symptoms than nonadherents on stimulants (n = 15) and those off medication (n = 14) (p =.04). At year 2 medication status (beta = 4.67 [0.40-8.95, p =.033]) and at year 5 adherence status (beta = 7.23 [3.01-11.44, p =.001]) correlated with higher teacher-reported symptom scores. Clinically significant adverse effects were present for 5 years, most commonly loss of appetite.

CONCLUSIONS

Psychostimulants improve ADHD symptoms for up to 5 years, but adverse effects persist.

Methylphenidate treatment of attention-deficit/hyperactivity disorder secondary to traumatic brain injury: a critical appraisal of treatment studies

OBJECTIVE

Are stimulants effective in treating attention-deficit/hyperactivity disorder secondary to traumatic brain injury (ADHD/TBI)? The authors reviewed and examined the current knowledge on efficacy of stimulant treatment ADHD/TBI.

METHOD

A systematic review of the literature using a quality assessment scale to assess the quality of randomized clinical trials was undertaken. We identified all studies in which stimulants had been administered to individuals with ADHD/TBI. Information was extracted on study characteristics, interventions, and outcomes. A meta-analysis was not performed because of the limited number of studies with strict research design and the heterogeneity of outcome measures. Seven studies involving 118 subjects, 41 of whom were children and adolescents, were identified.

RESULTS

Of the seven identified studies, one was a chart review, one used a single-blind, placebo-controlled crossover design, and five were double-blind, placebo-controlled crossovers. These studies used >50 subjective and objective tests to measure behavioral and cognitive outcomes. Methylphenidate (MPH) effects on behavior (hyperactivity, impulsivity) were evident but were not as robust as those typically observed with MPH in primary ADHD. The effect of MPH on cognition was less apparent. More favorable outcome was associated with initiation of treatment soon after head injury, although this factor was not systematically studied, and trials with relatively long durations. Studies with negative MPH response reported neither improvement in behavioral nor cognitive symptoms.

CONCLUSION

There is only modest evidence to support the efficacy of MPH in the treatment of ADHD/TBI. While MPH might still be a promising treatment for ADHD/TBI, there is need for rigorous treatment outcome research among representative samples of ADHD/TBI individuals.

Forty years of methylphenidate treatment in Attention-Deficit/ Hyperactivity Disorder

This paper reviews approximately 40 years of stimulant drug treatment of children with behavior and learning problems. These patients generally fall under the rubric of Attention-Deficit/Hyperactivity Disorder (ADHD), with core symptoms of hyperactivity, impulsivity, and inattention being the most studied and most robust of the targets for stimulant treatment. In addition, the drug effects on other targets, such as cognitive and academic function, are included. The largest selection of studies involves methylphenidate. Both qualitative studies and meta-analytic studies from major reviews are examined. Variations in the methodology of the reviews are described and some of the discrepancies in interpretation examined. Despite wide variations in subject selection, types of trials, degree of methodological rigor, and the decade in which the studies took place, the evidence is remarkably consistent The overall results suggest significant clinical impact upon the core features of ADHD. More studies of long-term effects and special populations such as older adolescents and adults will be necessary, though existing evidence strongly supports similar findings as for the younger patients with a diagnosis of ADHD.

Compliance with stimulants for attention-deficit/hyperactivity disorder: issues and approaches for improvement

Attention-deficit/hyperactivity disorder (ADHD) affects approximately 8-10% of school-aged children in the US and for many individuals persists into adolescence and adulthood. Both pharmacological and nonpharmacological (behavioural) therapies are used to treat individuals with ADHD. Treatment with stimulant medications, which include methylphenidate and amphetamine, typically requires multiple daily doses to maintain efficacy. The frequency of treatment, coupled with the importance of timing of doses and the long-term nature of treatment, make noncompliance a particular issue in the treatment of ADHD. Studies report noncompliance rates of 20-65% with stimulant treatment, although there are only limited published studies and these show considerable individual variation. Noncompliance can arise through inadequate supervision of those receiving medication, leading to delayed or missed doses, or through the reluctance of individuals to take medication, which is influenced by a number of factors (e.g. social attitudes, pressures or worries surrounding medication use and the inconvenience of multiple daily doses). Two approaches are likely to increase compliance with stimulant treatment: effective once-daily formulations of medication and improved treatment information. The development of effective once-daily formulations for stimulant treatments removes the need for multiple daily doses, with the associated problems of ensuring adequate treatment supervision and personal privacy. Improved provision of education and information for individuals with ADHD, as well as their families and teachers, should help them address the issues surrounding stimulant medication and allow full participation in the treatment process. Together, these strategies should improve treatment compliance for individuals with ADHD.

Attention-deficit hyperactivity disorder: critical appraisal of extended treatment studies

We undertook a systematic review of the literature on the long-term treatment of attention-deficit hyperactivity disorder (ADHD). We used systematic strategies to identify randomized treatment studies in which treatment was administered for 12 weeks or more. We included 14 studies involving 1379 subjects. Because of the limited number of high-quality studies and the heterogeneity of outcome measures, we did not perform meta-analysis. We rated 5 studies as adequate for methodological quality. Five studies followed children for more than 26 weeks. Pharmacologic interventions were studied more frequently than non-pharmacologic ones. Six studies permitted evaluation of the effects of combined drug and behavioural intervention. Twenty-five different outcomes were measured using 26 different tests. Stimulant medication appears to reduce ADHD (7 studies), dysfunctional social behaviour (6 studies), and internalizing symptoms (2 studies). Available studies provide little evidence for improved academic performance with stimulants (3 studies). Medications other than stimulants have not been studied extensively (3 studies). Only 1 study showed that combination therapy adds to the effects of medication. Rigorous treatment research among representative samples of ADHD individuals is needed.

Moderators and mediators of long-term adherence to stimulant treatment in children with ADHD

OBJECTIVE

To identify moderators and mediators of long-term adherence to stimulant medication in children with attention-deficit hyperactivity disorder (ADHD).

METHOD

Seventy-one children with ADHD were prescribed methylphenidate, followed prospectively on an annual basis for 3 years, and evaluated for adherence to stimulant treatment. The study occurred in Toronto between 1993 and 1997. Adherents were those who took methylphenidate, or another psychostimulant, for 5 or more days per week throughout the follow-up period, except for "drug holidays." Children who adhered at consecutive evaluations were compared with those who did not. Severity of ADHD, presence of oppositional defiant disorder/conduct disorder, learning difficulties, anxiety, age, family dysfunction, and socioeconomic adversity at baseline were investigated as moderators of adherence. Response to treatment at school, measured at 12 months, was investigated as a mediator of adherence.

RESULTS

Fifty-two percent of children adhered to stimulant treatment for 3 years. Absence of teacher-rated oppositional defiant disorder, more teacher-rated ADHD symptoms, and younger age at baseline predicted adherence.

CONCLUSIONS

Adherence to stimulant medications is a significant factor in the long-term treatment of children with ADHD.