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Masi G, Carucci S, Muratori P, Balia C, Sesso G, Milone A. Contemporary diagnosis and treatment of conduct disorder in youth. Expert Rev Neurother 2023; 23:1277-1296. [PMID: 37853718 DOI: 10.1080/14737175.2023.2271169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 10/04/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Conduct disorder (CD) is characterized by repetitive and persistent antisocial behaviors, being among the most frequently reported reasons of referral in youth. CD is a highly heterogeneous disorder, with possible specifiers defined according to age at onset, Limited Prosocial Emotions (LPE) otherwise known as Callous-Unemotional (CU) traits, Emotional Dysregulation (ED), and patterns of comorbidity, each with its own specific developmental trajectories. AREAS COVERED The authors review the evidence from published literature on the clinical presentations, diagnostic procedures, psychotherapeutic and psychoeducational approaches, and pharmacological interventions from RCT and naturalistic studies in youth. Evidence from studies including youths with LPE/CU traits, ED and aggression are also reviewed, as response moderators. EXPERT OPINION Due to its clinical heterogeneity, relevant subtypes of CD should be carefully characterized to gain reliable information on prognosis and treatments. Thus, disentangling this broad category in subtypes is crucial as a first step in diagnosis. Psychosocial interventions are the first option, possibly improving LPE/CU traits and ED, especially if implemented early during development. Instead, limited information, based on low-quality studies, supports pharmacological options. Second-generation antipsychotics, mood stabilizers, and stimulants are first-line medications, according to different target symptoms, such as aggression and emotional reactivity. Developmental pathways including ADHD suggest a specific role of psychostimulants.
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Affiliation(s)
- Gabriele Masi
- Department of Child and Adolescent Psychiatry and Psychopharmacology, IRCCS Stella Maris Foundation, Pisa, Italy
| | - Sara Carucci
- Department of Biomedical Science, Section of Neuroscience & Clinical Pharmacology, University of Cagliari, Cagliari, Italy
- Child & Adolescent Neuropsychiatric Unit, "A. Cao" Paediatric Hospital-ARNAS "G. Brotzu" Hospital Trust, Department of Paediatrics, Cagliari, Italy
| | - Pietro Muratori
- Department of Child and Adolescent Psychiatry and Psychopharmacology, IRCCS Stella Maris Foundation, Pisa, Italy
| | - Carla Balia
- Department of Biomedical Science, Section of Neuroscience & Clinical Pharmacology, University of Cagliari, Cagliari, Italy
- Child & Adolescent Neuropsychiatric Unit, "A. Cao" Paediatric Hospital-ARNAS "G. Brotzu" Hospital Trust, Department of Paediatrics, Cagliari, Italy
| | - Gianluca Sesso
- Department of Child and Adolescent Psychiatry and Psychopharmacology, IRCCS Stella Maris Foundation, Pisa, Italy
- Social and Affective Neuroscience Group, Molecular Mind Lab, IMT School for Advanced Studies Lucca, Lucca, Italy
| | - Annarita Milone
- Department of Child and Adolescent Psychiatry and Psychopharmacology, IRCCS Stella Maris Foundation, Pisa, Italy
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Seok JW, Soltis-Vaughan B, Lew BJ, Ahmad A, Blair RJR, Hwang S. Psychopharmacological treatment of disruptive behavior in youths: systematic review and network meta-analysis. Sci Rep 2023; 13:6921. [PMID: 37117632 PMCID: PMC10147946 DOI: 10.1038/s41598-023-33979-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 04/21/2023] [Indexed: 04/30/2023] Open
Abstract
To conduct a systematic review of the comparative efficacy of various psychotropic medications for the treatment of disruptive behavior (DBs) in youths. To this aim, we systematically reviewed randomized clinical trials (RCTs) of various psychotropic medications targeting symptoms of DBs and applied network meta-analysis to investigate their relative efficacy. Fifty-five RCTs meeting the inclusion criteria were selected. To predict and interpret relative treatment efficacy, we compared the efficacy of various psychotropic medications prescribed for DB symptoms based on their mechanism of action. Network meta-analysis revealed that for reducing DBs, second-generation antipsychotics, stimulants, and non-stimulant ADHD medications were more efficacious than placebo, and second-generation antipsychotics were the most efficacious. The dopaminergic modulation of top-down inhibitory process by these medications is discussed in this review. This study offers information on the relative efficacy of various psychotropic medications for the treatment of DB, and insight into a potential neurobiological underpinning for those symptoms. It also illustrates the potential utility of these neurobiological mechanisms as a target for future treatment studies.
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Affiliation(s)
- Ji-Woo Seok
- Department of Psychiatry, University of Nebraska Medical Center, 985578 Nebraska Medical Center, Omaha, NE, 68198-5578, USA
- Digital Health Research Division, Korea Institute of Oriental Medicine, Daejeon, South Korea
| | - Brigette Soltis-Vaughan
- Department of Psychiatry, University of Nebraska Medical Center, 985578 Nebraska Medical Center, Omaha, NE, 68198-5578, USA
| | - Brandon J Lew
- Department of Psychiatry, University of Nebraska Medical Center, 985578 Nebraska Medical Center, Omaha, NE, 68198-5578, USA
| | - Aatiya Ahmad
- Department of Psychiatry, University of Nebraska Medical Center, 985578 Nebraska Medical Center, Omaha, NE, 68198-5578, USA
| | - R J R Blair
- Child and Adolescent Mental Health Centre, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark
| | - Soonjo Hwang
- Department of Psychiatry, University of Nebraska Medical Center, 985578 Nebraska Medical Center, Omaha, NE, 68198-5578, USA.
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Efficacy and Safety of Medication for Attention-Deficit Hyperactivity Disorder in Children and Adolescents with Common Comorbidities: A Systematic Review. Neurol Ther 2021; 10:499-522. [PMID: 34089145 PMCID: PMC8571469 DOI: 10.1007/s40120-021-00249-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/09/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction Comorbid psychiatric conditions in children and adolescents with attention-deficit hyperactivity disorder (ADHD) occur frequently, complicate management, and are associated with substantial burden on patients and caregivers. Very few systematic reviews have assessed the efficacy and safety of medications for ADHD in children and adolescents with comorbidities. Of those that were conducted, most focused on a particular comorbidity or medication. In this systematic literature review, we summarize the efficacy and safety of treatments for children and adolescents with ADHD and comorbid autism spectrum disorders, oppositional defiant disorder, Tourette’s disorder and other tic disorders, generalized anxiety disorder, and major depressive disorder. Methods We searched MEDLINE, Embase, and ClinicalTrials.gov (to October 2019) for studies of patients (aged < 18 years) with an ADHD diagnosis and the specified comorbidities treated with amphetamines, methylphenidate and derivatives, atomoxetine (ATX), and guanfacine extended-release (GXR). For efficacy, placebo-controlled randomized controlled trials (RCTs) or meta-analyses of RCTs were eligible for inclusion; for safety, all study types were eligible. The primary efficacy outcome measure was ADHD Rating Scale IV (ADHD-RS-IV) total score. Results Of 2177 publications/trials retrieved, 69 were included in this systematic literature review (5 meta-analyses, 37 placebo-controlled RCTs, 16 cohort studies, 11 case reports). A systematic narrative synthesis is provided because insufficient data were retrieved to combine ADHD-RS-IV total scores or effect sizes. Effect sizes for ADHD-RS-IV total scores were available for ten RCTs and ranged from 0.46 to 1.0 for ATX and from 0.92 to 2.0 for GXR across comorbidities. The numbers and types of adverse events in children with comorbidities were consistent with those in children without comorbidities, but treatment should be individualized to ensure children can tolerate the lowest effective dose. Conclusion Limited information is available from placebo-controlled RCTs on the efficacy (by ADHD-RS-IV) or safety of medication in children with ADHD and psychiatric comorbidities. Further studies are required to support evidence-based drug selection for these populations. Supplementary Information The online version contains supplementary material available at 10.1007/s40120-021-00249-0.
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Fu D, Wu DD, Guo HL, Hu YH, Xia Y, Ji X, Fang WR, Li YM, Xu J, Chen F, Liu QQ. The Mechanism, Clinical Efficacy, Safety, and Dosage Regimen of Atomoxetine for ADHD Therapy in Children: A Narrative Review. Front Psychiatry 2021; 12:780921. [PMID: 35222104 PMCID: PMC8863678 DOI: 10.3389/fpsyt.2021.780921] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/28/2021] [Indexed: 12/12/2022] Open
Abstract
Atomoxetine, a selective norepinephrine (NE) reuptake inhibitor, was approved for attention deficit/hyperactivity disorder (ADHD) treatment in children, adolescents and adults. We searched the database PubMed/MEDLINE (2000 to October 1, 2021). Only publications in English were considered. Atomoxetine inhibits the presynaptic norepinephrine transporter (NET), preventing the reuptake of NE throughout the brain along with inhibiting the reuptake of dopamine in specific brain regions such as the prefrontal cortex (PFC). The novel mechanism of atomoxetine also includes several new brain imaging studies and animal model studies. It is mainly metabolized by the highly polymorphic drug metabolizing enzyme cytochrome P450 2D6 (CYP2D6). Atomoxetine is effective and generally well tolerated. ADHD is often accompanied by multiple comorbidities. A series of studies have been published suggesting that atomoxetine is effective in the treatment of ADHD symptoms for children with various types of comorbidity. In some cases, it is possible that atomoxetine may have a positive influence on the symptoms of comorbidities. Atomoxetine can be administered either as a single daily dose or split into two evenly divided doses, and has a negligible risk of abuse or misuse. The latest guideline updated that clinical dose selection of atomoxetine was recommended based on both CYP2D6 genotype and the peak concentration. To have a more comprehensive understanding of atomoxetine, this review sets the focus on the mechanism, clinical efficacy and dosage regimen in detail, and also touches on those studies regarding adverse reactions of atomoxetine.
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Affiliation(s)
- Di Fu
- Department of Pharmacy, Pharmaceutical Sciences Research Center, Children's Hospital of Nanjing Medical University, Nanjing, China.,School of Basic Medical Sciences and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Dan-Dan Wu
- Department of Children Health Care, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Hong-Li Guo
- Department of Pharmacy, Pharmaceutical Sciences Research Center, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ya-Hui Hu
- Department of Pharmacy, Pharmaceutical Sciences Research Center, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ying Xia
- Department of Pharmacy, Pharmaceutical Sciences Research Center, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xing Ji
- Department of Pharmacy, Pharmaceutical Sciences Research Center, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Wei-Rong Fang
- School of Basic Medical Sciences and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Yun-Man Li
- School of Basic Medical Sciences and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Jing Xu
- Department of Pharmacy, Pharmaceutical Sciences Research Center, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Feng Chen
- Department of Pharmacy, Pharmaceutical Sciences Research Center, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Qian-Qi Liu
- Department of Children Health Care, Children's Hospital of Nanjing Medical University, Nanjing, China
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Efficacy of Guanfacine Extended Release in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder and Comorbid Oppositional Defiant Disorder. J Dev Behav Pediatr 2020; 41:565-570. [PMID: 32482970 DOI: 10.1097/dbp.0000000000000822] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To assess the efficacy of the non-stimulant guanfacine extended release (GXR) on attention-deficit/hyperactivity disorder (ADHD) symptoms in children and adolescents, with and without comorbid oppositional defiant disorder (ODD). METHODS Data were derived from 4 phase 3, randomized, placebo-controlled trials of dose-optimized GXR monotherapy, in which at least 10% of participants had a diagnosis of comorbid ODD. SPD503-312 and SPD503-316 were 10- to 13-week studies of GXR (1-7 mg/d). SPD503-314 and SPD503-307 were 8-week studies of GXR (1-4 mg/d). Efficacy was assessed using the ADHD Rating Scale IV (ADHD-RS-IV) total scores. RESULTS In total, 1,084 participants were included (SPD503-312 and SPD503-316, n = 537; SPD503-314, n = 333; and SPD503-307, n = 214). GXR was associated with significant improvements in ADHD core symptoms at endpoint in participants with and without ODD (p < 0.01 in all studies). Placebo-adjusted least-squares mean (95% confidence interval) changes from baseline to endpoint in the ADHD-RS-IV total scores in participants with and without ODD were -8.6 (-14.4, -2.8) and -7.3 (-9.5, -5.0) in the pooled data from SPD503-312 and SPD503-316, -12.6 (-19.6, -5.7) and -8.7 (-11.8, -5.5) in SPD503-314, and -12.7 (-17.3, -8.1) and -11.8 (-19.3, -4.4) in SPD503-307, respectively. The corresponding effect sizes were 0.688 and 0.598 in SPD503-312 and SPD503-316, 0.876 and 0.729 in SPD503-314, and 0.962 and 0.842 in SPD503-307. CONCLUSION The findings demonstrate the efficacy of GXR for treating ADHD in children and adolescents with comorbid ODD.
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Griffiths KR, Jurigova BG, Leikauf JE, Palmer D, Clarke SD, Tsang TW, Teber ET, Kohn MR, Williams LM. A Signature of Attention-Elicited Electrocortical Activity Distinguishes Response From Non-Response to the Non-Stimulant Atomoxetine in Children and Adolescents With ADHD. J Atten Disord 2019; 23:744-753. [PMID: 28974127 PMCID: PMC8215986 DOI: 10.1177/1087054717733044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Atomoxetine has several characteristics that make it an attractive alternative to stimulants for treating ADHD, but there are currently no tests identifying individuals for whom the medication should be a first-line option. METHOD Within the ADHD Controlled Trial Investigation Of a Non-stimulant (ACTION) study, we examined neuro-cortical activity in 52 youth with ADHD. Baseline event-related potentials (ERP) were compared between those who subsequently responded to 6 weeks of atomoxetine versus those who did not. RESULTS Responders were distinguished by significantly lower auditory oddball N2 amplitudes than both non-responders and typically developing controls, particularly in the right frontocentral region ( p = .002, Cohen's d = 1.1). Leave-one-out cross validation determined that N2 amplitude in this region was able to accurately predict non-responders with a specificity of 80.8%. There were no P3 differences between responders and non-responders. CONCLUSION The N2 amplitude is a biomarker that may have utility in predicting response to atomoxetine for youth with ADHD.
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Affiliation(s)
- Kristi R. Griffiths
- Brain Dynamics Centre, The Westmead Institue for Medical Research, The University of Sydney, Westmead, New South Wales, Australia
| | - Barbora G. Jurigova
- Brain Dynamics Centre, The Westmead Institue for Medical Research, The University of Sydney, Westmead, New South Wales, Australia
| | - John E. Leikauf
- Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA, USA
| | - Donna Palmer
- Brain Resource, Sydney, New South Wales, Australia
| | - Simon D. Clarke
- Brain Dynamics Centre, The Westmead Institue for Medical Research, The University of Sydney, Westmead, New South Wales, Australia,Adolescent & Young Adult Medicine, Westmead Hospital, Westmead, New South Wales, Australia,Centre for Research into Adolescents Health, Westmead, New South Wales, Australia
| | - Tracey W. Tsang
- Brain Dynamics Centre, The Westmead Institue for Medical Research, The University of Sydney, Westmead, New South Wales, Australia,Discipline of Child & Adolescent Health, Sydney Medical School, University of Sydney, New South Wales, Australia
| | - Erdahl T. Teber
- Children's Medical Research Institute, Westmead, New South Wales, Australia
| | - Michael R. Kohn
- Brain Dynamics Centre, The Westmead Institue for Medical Research, The University of Sydney, Westmead, New South Wales, Australia,Adolescent & Young Adult Medicine, Westmead Hospital, Westmead, New South Wales, Australia,Centre for Research into Adolescents Health, Westmead, New South Wales, Australia
| | - Leanne M. Williams
- Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA, USA
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Khan S, Down J, Aouira N, Bor W, Haywood A, Littlewood R, Heussler H, McDermott B. Current pharmacotherapy options for conduct disorders in adolescents and children. Expert Opin Pharmacother 2019; 20:571-583. [PMID: 30702354 DOI: 10.1080/14656566.2018.1561862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Conduct disorder (CD) is a common mental health disorder of childhood and adolescence. CD's complexity, with its heterogenous clinical manifestations and overlapping comorbidities makes the application of evidence-based management approaches challenging. This article aims to combine a systematic review of the available literature, with a consensus opinion from both child and adolescent psychiatrists and developmental pediatricians on the clinical and pharmacological management of children and adolescents with conduct disorder (CD). AREAS COVERED The authors review the CD population and provide a systematic review and meta-analysis of the effectiveness and safety of pharmacotherapies using preferred reporting items for systematic review and meta-analysis (PRISMA) and strength of evidence recommendation taxonomy (SORT) guidelines. The authors then provide an expert clinical opinion for the use of different pharmacotherapies to address aggressive and disruptive behavior in children. EXPERT OPINION Atypical antipsychotics (e.g. risperidone) demonstrate evidence for efficacy in CD. Other pharmacotherapies (e.g. mood stabilizers, anticonvulsants, psychostimulants and selective norepinephrine reuptake inhibitors) have a low level of evidence for CD alone, however, can sometimes be effective in managing the symptoms of CD when other psychiatric disorders are also present.
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Affiliation(s)
- Sohil Khan
- a School of Pharmacy and Pharmacology, Quality Use of Medicines Network, Menzies Health Institute , Griffith University , Gold Coast , Australia.,b Mater Research Institute , The University of Queensland , South Brisbane , Australia.,c Manipal College of Pharmaceutical Sciences , Manipal University , Manipal , India
| | - John Down
- d Children's Health Queensland Hospital and Health Service , Lady Cilento Children's Hospital , South Brisbane , Australia
| | - Nisreen Aouira
- a School of Pharmacy and Pharmacology, Quality Use of Medicines Network, Menzies Health Institute , Griffith University , Gold Coast , Australia
| | - William Bor
- b Mater Research Institute , The University of Queensland , South Brisbane , Australia.,e Child and Youth Mental Health Service , Children's Health Queensland Hospital and Health Service , South Brisbane , Australia.,f Centre for Children's Health Research , Children's Health Queensland Hospital and Health Services , South Brisbane , Australia
| | - Alison Haywood
- a School of Pharmacy and Pharmacology, Quality Use of Medicines Network, Menzies Health Institute , Griffith University , Gold Coast , Australia.,b Mater Research Institute , The University of Queensland , South Brisbane , Australia
| | - Robyn Littlewood
- e Child and Youth Mental Health Service , Children's Health Queensland Hospital and Health Service , South Brisbane , Australia.,f Centre for Children's Health Research , Children's Health Queensland Hospital and Health Services , South Brisbane , Australia.,g School of Human Movement and Nutrition Sciences , The University of Queensland , South Brisbane , Australia
| | - Helen Heussler
- b Mater Research Institute , The University of Queensland , South Brisbane , Australia.,d Children's Health Queensland Hospital and Health Service , Lady Cilento Children's Hospital , South Brisbane , Australia.,f Centre for Children's Health Research , Children's Health Queensland Hospital and Health Services , South Brisbane , Australia
| | - Brett McDermott
- h Townsville Clinical School, College of Medicine and Dentistry , James Cook University , Townsville , Australia
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Sha'ari N, Manaf ZA, Ahmad M, Rahman FNA. Nutritional status and feeding problems in pediatric attention deficit-hyperactivity disorder. Pediatr Int 2017; 59:408-415. [PMID: 27805287 DOI: 10.1111/ped.13196] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 08/02/2016] [Accepted: 09/30/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Children with attention deficit-hyperactivity disorder (ADHD) may be at risk of nutrient deficiency due to the inability to sit through meals. This comparative cross-sectional study was therefore carried out to determine the nutritional status and feeding problems of ADHD children aged 4-12 years. METHODS Sociodemographic data, anthropometric measurements and 3 day dietary intake record were collected from 54 ADHD children and 54 typical development (TD) children. The Behavioral Pediatrics Feeding Assessment Scale was used to assess feeding problems. RESULTS Mean subject age was 8.6 ± 2.1 years. On anthropometric assessment, 11.1% of the ADHD children had wasting, while 1.9% had severe wasting. In contrast, none of the TD children had wasting. Approximately 5.6% of the ADHD children had stunting, as compared with 3.7% of the TD children, while none of the TD children had severe stunting compared with 3.7% of the ADHD children. More than half of the ADHD children had mid-upper arm circumference (MUAC) below the 5th percentile, indicating undernutrition, compared with only 35.2% of TD children. More than one-third of the ADHD children had feeding problems compared with 9.3% of TD children. There was a significant negative relationship between the ADHD children's feeding problems and bodyweight (r = -0338, P = 0.012), body mass index (r = -0322, P = 0.017) and MUAC (r = -0384, P = 0.004). CONCLUSION Almost half of the ADHD children had suboptimal nutrition compared with 11.1% of the TD children. It is imperative to screen ADHD children for nutritional status and feeding problems to prevent negative health impacts later on.
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Affiliation(s)
- Norsuhaila Sha'ari
- Department of Dietetics and Food Service, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
| | - Zahara Abdul Manaf
- Dietetic Department, Faculty of Health Sciences, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Mahadir Ahmad
- Health Psychology Programme, Faculty of Health Sciences, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Fairuz Nazri Abd Rahman
- Psychiatry Department, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
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Balia C, Carucci S, Coghill D, Zuddas A. The pharmacological treatment of aggression in children and adolescents with conduct disorder. Do callous-unemotional traits modulate the efficacy of medication? Neurosci Biobehav Rev 2017; 91:218-238. [PMID: 28137460 DOI: 10.1016/j.neubiorev.2017.01.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 12/07/2016] [Accepted: 01/20/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Children and adolescents with conduct disorder (CD) show repetitive and persistent patterns of aggressive behaviour and the more severe forms are often associated with callous-unemotional (CU) traits. OBJECTIVES To systematically review and, where data are adequate, conduct meta-analyses on the efficacy of medication on aggression in children and adolescent with CD considering the impact of CU traits. RESULTS Few studies have investigated patients with CD as primary diagnosis, and few of these have discriminated between different types of aggression or reported measures of CU traits. Methylphenidate and risperidone showed the largest effects on aggression in randomized controlled trials; other antipsychotics showed clinical efficacy on CD but this evidence is mainly revealed by open label trials. There is some low quality evidence to support a small effect of mood stabilizers and other agents. There were only two papers describing the effects of CU traits thus providing inconclusive results. CONCLUSION Considering heterogeneity of the disorder, more proof-of-concept clinical studies are needed to define effects of medication and role of CU traits.
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Affiliation(s)
- Carla Balia
- Child & Adolescent Neuropsychiatric Unit, Department of Biomedical Science, University of Cagliari & "A. Cao" Microcitemico Paediatric Hospital, Cagliari, Italy
| | - Sara Carucci
- Child & Adolescent Neuropsychiatric Unit, Department of Biomedical Science, University of Cagliari & "A. Cao" Microcitemico Paediatric Hospital, Cagliari, Italy.
| | - David Coghill
- Division of Neuroscience, University of Dundee, Dundee, UK; Departments of Paediatrics and Psychiatry, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia
| | - Alessandro Zuddas
- Child & Adolescent Neuropsychiatric Unit, Department of Biomedical Science, University of Cagliari & "A. Cao" Microcitemico Paediatric Hospital, Cagliari, Italy
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Clemow DB, Bushe C, Mancini M, Ossipov MH, Upadhyaya H. A review of the efficacy of atomoxetine in the treatment of attention-deficit hyperactivity disorder in children and adult patients with common comorbidities. Neuropsychiatr Dis Treat 2017; 13:357-371. [PMID: 28223809 PMCID: PMC5304987 DOI: 10.2147/ndt.s115707] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Attention-deficit hyperactivity disorder (ADHD) is a common neuropsychiatric disorder that is often diagnosed during childhood, but has also increasingly been recognized to occur in adults. Importantly, up to 52% of children (including adolescents) and 87% of adults with ADHD also have a comorbid psychiatric disorder. The presence of a comorbid disorder has the potential to impact diagnosis and could affect treatment outcomes. Atomoxetine is a nonstimulant treatment for ADHD. Despite numerous published studies regarding efficacy of atomoxetine in the treatment of ADHD in patients with comorbid disorders, there is limited information about the impact of individual common comorbid disorders on the efficacy of atomoxetine for ADHD, especially with regard to adults. Moreover, a cumulative review and assessment of these studies has not been conducted. For this reason, we performed a literature review to find, identify, and cumulatively review clinical studies that examined the efficacy of atomoxetine in the treatment of patients with ADHD and comorbid psychiatric disorders. We found a total of 50 clinical studies (37 in children; 13 in adults) that examined the efficacy of atomoxetine in patients with ADHD and a comorbid disorder. The comorbidities that were studied in children or in adults included anxiety, depression, and substance use disorder. Overall, the presence of comorbidity did not adversely impact the efficacy of atomoxetine in treatment of ADHD symptoms in both patient populations. In the studies identified and assessed in this review, atomoxetine did not appear to exacerbate any of the comorbid conditions and could, therefore, be an important therapy choice for the treatment of ADHD in the presence of comorbid disorders.
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Luan R, Mu Z, Yue F, He S. Efficacy and Tolerability of Different Interventions in Children and Adolescents with Attention Deficit Hyperactivity Disorder. Front Psychiatry 2017; 8:229. [PMID: 29180967 PMCID: PMC5694170 DOI: 10.3389/fpsyt.2017.00229] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 10/25/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Our study is an analysis of multiple publications involving assessing the comparable efficacy and tolerability of six interventions, which are lisdexamfetamine dimesylate (LDX), atomoxetine (ATX), methylphenidate (MPH), clonidine hydrochloride (CLON), guanfacine extended release (GXR), and bupropion, for young patients (6-18 years old) suffering from attention deficit hyperactivity disorder (ADHD). METHODS A conventional meta-analysis (MA) was performed to give direct comparisons and a network meta-analysis (NMA) was used to show the combination of direct and indirect evidence. Ranking preference for all the interventions under a certain outcome was given by the surface of cumulative ranking curve area (SUCRA). RESULTS Overall, 15,025 participants from 73 studies were involved in our analysis. In the pairwise MA, LDX was associated with less withdrawal than ATX for lack of efficacy. MPH showed less effectiveness than LDX according to ADHD Rating Scale score. Based on the analysis of our NMA, significant results of efficacy that LDX is a competitive drug were observed when evaluating LDX in comparison with other drugs except for CLON. ATX and GXR presented higher rates of abdominal pain morbidity versus inactive treatment. CONCLUSION The stimulants LDX and MPH are still highly recommended because they are highly effective and are tolerated well by patients. Among the non-stimulants, CLON can be taken into consideration for its appreciable effectiveness and tolerability. ATX and GXR can be seen as moderate choices.
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Affiliation(s)
- Ruiling Luan
- Department of Pharmacy, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Zhiling Mu
- Department of Pediatrics, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Fang Yue
- Department of Pediatrics, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Shaoying He
- Department of Pediatrics, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
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12
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Li Y, Gao J, He S, Zhang Y, Wang Q. An Evaluation on the Efficacy and Safety of Treatments for Attention Deficit Hyperactivity Disorder in Children and Adolescents: a Comparison of Multiple Treatments. Mol Neurobiol 2016; 54:6655-6669. [DOI: 10.1007/s12035-016-0179-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 09/28/2016] [Indexed: 11/25/2022]
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13
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Hambly JL, Khan S, McDermott B, Bor W, Haywood A. Pharmacotherapy of conduct disorder: Challenges, options and future directions. J Psychopharmacol 2016; 30:967-75. [PMID: 27436231 DOI: 10.1177/0269881116658985] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
UNLABELLED There is a critical need for evaluation of the pharmacotherapies used in conduct disorder (CD), due to the high incidence of off-label prescribing. The aim of this review was to identify concerns associated with the safety, efficacy and impact on quality of life (QOL) that pharmacotherapy has in children and adolescents with CD. A systematic review was undertaken using pre-defined search criteria and four databases, including reference searches. We assessed these studies using the Strength of Recommendation Taxonomy, Grading of Recommendations Assessment, Development and Evaluation, and Review Manager Risk of Bias (RevMan®) tools. There were 12 randomised controlled trials that met our inclusion criteria. STUDIES INCLUDED antipsychotics, atomoxetine, lithium, clonidine, divalproex sodium and psychostimulants. The antipsychotics demonstrated efficacy, but were associated with adverse effects. Other agents demonstrated mixed responses, highlighting the lack of clinical significance and increased incidence of adverse effects. The management of related adverse effects was addressed to assist with clinical gaps. Overall, there is limited evidence regarding the role of pharmacotherapy in CD. More research is needed that takes into account the heterogeneity of CD and analysis of pharmacotherapy in pure CD.
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Affiliation(s)
- Jessica L Hambly
- School of Pharmacy, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
| | - Sohil Khan
- School of Pharmacy, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia Mater Research Institute - The University of Queensland, Brisbane, QLD, Australia Manipal College of Pharmaceutical Sciences, Manipal University, Manipal, India
| | - Brett McDermott
- Townsville Clinical School, College of Medicine and Dentistry, James Cook University, Queensland, QLD, Australia
| | - William Bor
- Mater Research Institute - The University of Queensland, Brisbane, QLD, Australia Child and Youth Mental Health Service, Centre for Children's Health Research, Queensland Health, Brisbane, QLD, Australia
| | - Alison Haywood
- School of Pharmacy, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia Mater Research Institute - The University of Queensland, Brisbane, QLD, Australia
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Wehmeier PM, Kipp L, Banaschewski T, Dittmann RW, Schacht A. Does Comorbid Disruptive Behavior Modify the Effects of Atomoxetine on ADHD Symptoms as Measured by a Continuous Performance Test and a Motion Tracking Device? J Atten Disord 2015; 19:591-602. [PMID: 22930789 DOI: 10.1177/1087054712456739] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To compare the reduction of ADHD symptoms under atomoxetine in patients with and without comorbid oppositional defiant disorder (ODD) or conduct disorder (CD) using a computer-based continuous performance test (cb-CPT) combined with an infrared motion tracking (MT) device. METHOD Secondary analysis of a placebo-controlled study in ADHD patients (6-12 years old) treated with atomoxetine (target dose: 1.2 mg/kg per day). Cb-CPT/MT scores were analyzed using ANCOVA (last observation carried forward [LOCF]). RESULTS The data (N = 125) suggested a more pronounced atomoxetine effect in the group with comorbid ODD/CD as measured by all cb-CPT/MT parameters except for "normalized variation of reaction time" (nVRT). CONCLUSION The results showed that atomoxetine reduced ADHD severity as measured by cb-CPT and MT parameters regardless of whether comorbid ODD/CD was present. The treatment effect of atomoxetine on hyperactivity appears to be more pronounced in the subgroup of patients with comorbid ODD/CD than in the subgroup without this comorbidity.
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Affiliation(s)
- Peter M Wehmeier
- Department of Child and Adolescent Psychiatry, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Germany Vitos Hospital for Psychiatry and Psychotherapy, Weilmuenster, Germany
| | - Laura Kipp
- Department of Child and Adolescent Psychiatry, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Tobias Banaschewski
- Department of Child and Adolescent Psychiatry, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Ralf W Dittmann
- Eli Lilly Endowed Chair of Pediatric Psychopharmacology at the Department of Child and Adolescent Psychiatry, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Germany
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Garg J, Arun P, Chavan BS. Comparative efficacy of methylphenidate and atomoxetine in oppositional defiant disorder comorbid with attention deficit hyperactivity disorder. Int J Appl Basic Med Res 2015; 5:114-8. [PMID: 26097819 PMCID: PMC4456885 DOI: 10.4103/2229-516x.157162] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 09/30/2014] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Oppositional defiant disorder (ODD) is frequently comorbid with attention deficit hyperactivity disorder (ADHD) and is associated with substantial functional impairments. Methylphenidate and atomoxetine are well-established drugs for the management of ADHD. Some studies from Western countries have reported these drugs to be effective in the management of ODD comorbid with ADHD. This study aimed to assess if methylphenidate and atomoxetine are efficacious in treating Indian children with ODD comorbid with ADHD. SUBJECTS AND METHODS In this prospective, open-label study, 37 patients of age 6-14 years with a diagnosis of ODD comorbid with ADHD randomly received either methylphenidate (dose 0.2-1 mg/kg/day) or atomoxetine (dose 0.5-1.2 mg/kg/day) for 8 weeks. Improvements in ADHD and ODD symptoms were assessed using Vanderbilt ADHD diagnostic parent rating scale (VADPRS). RESULTS At 8 weeks, there were statistically significant improvements in both ADHD and ODD symptoms in both methylphenidate and atomoxetine groups, as per VADPRS. The improvements produced and tolerability was comparable in the two groups. 80% of the patients from methylphenidate group and 64.3% patients from atomoxetine group ceased to fulfill the criteria for the presence of ODD at 8 weeks. CONCLUSIONS Methylphenidate and atomoxetine are effective in the treatment of ODD comorbid with ADHD in short duration.
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Affiliation(s)
- Jasmin Garg
- Department of Psychiatry, Government Medical College and Hospital, Sector 32, Chandigarh, India
| | - Priti Arun
- Department of Psychiatry, Government Medical College and Hospital, Sector 32, Chandigarh, India
| | - B S Chavan
- Department of Psychiatry, Government Medical College and Hospital, Sector 32, Chandigarh, India
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16
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Stuhec M, Munda B, Svab V, Locatelli I. Comparative efficacy and acceptability of atomoxetine, lisdexamfetamine, bupropion and methylphenidate in treatment of attention deficit hyperactivity disorder in children and adolescents: a meta-analysis with focus on bupropion. J Affect Disord 2015; 178:149-59. [PMID: 25813457 DOI: 10.1016/j.jad.2015.03.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 03/02/2015] [Accepted: 03/03/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVES There is a lack of comparative effectiveness research among attention deficit hyperactivity disorder (ADHD) drugs in terms of efficacy and acceptability, where bupropion is compared with atomoxetine, lisdexamfetamine and methylphenidate. The main aim of this work was to compare the efficacy and acceptability of these drugs in children and adolescents using a metaanalysis. METHODS A literature search was conducted to identify double-blind, placebo-controlled, noncrossover studies of ADHD. PubMed/Medline and Clinicaltrials.gov were searched. Comparative drug efficacy to placebo was calculated based on the standardized mean difference (SMD), while the comparative drug acceptability (all cause discontinuation) to placebo was estimated on the odds ratio (OR). RESULTS In total 28 trials were included in the meta-analysis. Efficacy in reducing ADHD symptoms compared to placebo was small for bupropion (SMD=-0.32, 95% CI; -0.69, 0.05), while modest efficacy was shown for atomoxetine (SMD=-0.68, 95% CI; -0.76, -0.59) and methylphenidate (SMD=-0.75, 95% CI; -0.98, -0.52) and high efficacy was observed for lisdexamfetamine (SMD=-1.28, 95% CI; -1.84, -0.71). Compared to placebo treatment discontinuation was statistically significantly lower for methylphenidate (OR=0.35, 95% CI; 0.24, 0.52), while it was not significantly different for atomoxetine (OR=0.91, 95% CI; 0.66, 1.24), lisdexamfetamine (OR=0.60, 95% CI, 0.22, 1.65), and bupropion (OR=1.64, 95% CI; 0.5, 5.43). LIMITATIONS The heterogeneity was high, except in atomoxetine trials. The crossover studies were excluded. The effect sizes at specific time points were not computed. Studies with comorbid conditions, except those reporting on oppositional defiant disorder, were also excluded. All studies involving MPH were combined. CONCLUSIONS The results suggest that lisdexamfetamine has the best benefit risk balance and has promising potential for treating children and adolescents with ADHD. More research is needed for a better clinical evaluation of bupropion.
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Affiliation(s)
- Matej Stuhec
- Clinical Pharmacy Department, Ormož Psychiatric hospital, Ptujska Cesta 33, 2270 Ormož, Slovenia, European Union.
| | - Barbara Munda
- Chair of Social Pharmacy, Faculty of Pharmacy, University of Ljubljana, Aškerčeva cesta 7, 1000 Ljubljana, Slovenia, European Union
| | - Vesna Svab
- Department of Psychiatry, Faculty of Medicine, University Ljubljana, Vrazov trg 2, 1104 Ljubljana, Slovenia, European Union
| | - Igor Locatelli
- Chair of Social Pharmacy, Faculty of Pharmacy, University of Ljubljana, Aškerčeva cesta 7, 1000 Ljubljana, Slovenia, European Union
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Savill NC, Buitelaar JK, Anand E, Day KA, Treuer T, Upadhyaya HP, Coghill D. The efficacy of atomoxetine for the treatment of children and adolescents with attention-deficit/hyperactivity disorder: a comprehensive review of over a decade of clinical research. CNS Drugs 2015; 29:131-51. [PMID: 25698145 DOI: 10.1007/s40263-014-0224-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Atomoxetine was first licensed to treat attention-deficit/hyperactivity disorder (ADHD) in children and adolescents in the US in 2002. The aim of this paper is to comprehensively review subsequent publications addressing the efficacy of atomoxetine in 6- to 18-year-olds with ADHD. We identified 125 eligible papers using a predefined search strategy. Overall, these papers demonstrate that atomoxetine is an effective treatment for the core ADHD symptoms (effect sizes 0.6-1.3, vs. placebo, at 6-18 weeks), and improves functional outcomes and quality of life, in various pediatric populations with ADHD (i.e., males/females, patients with co-morbidities, children/adolescents, and with/without prior exposure to other ADHD medications). Initial responses to atomoxetine may be apparent within 1 week of treatment, but can take longer (median 23 days in a 6-week study; n=72). Responses often build gradually over time, and may not be robust until after 3 months. A pooled analysis of six randomized placebo-controlled trials (n=618) indicated that responses at 4 weeks may predict response at 6-9 weeks, although another pooled analysis of open-label data (n=338) suggests that the probability of a robust response to atomoxetine [≥40% decrease in ADHD-Rating Scale (ADHD-RS) scores] may continue to increase beyond 6-9 weeks. Atomoxetine may demonstrate similar efficacy to methylphenidate, particularly immediate-release methylphenidate, although randomized controlled trials are generally limited by short durations (3-12 weeks). In conclusion, notwithstanding these positive findings, before initiating treatment with atomoxetine, it is important that the clinician sets appropriate expectations for the patient and their family with regard to the likelihood of a gradual response, which often builds over time.
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Affiliation(s)
- Nicola C Savill
- Eli Lilly and Co., Lilly House, Priestley Road, Basingstoke, Hampshire, RG24 9NL, UK,
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18
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Rostain A, Jensen PS, Connor DF, Miesle LM, Faraone SV. Toward quality care in ADHD: defining the goals of treatment. J Atten Disord 2015; 19:99-117. [PMID: 23422237 DOI: 10.1177/1087054712473835] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
| | - Peter S Jensen
- The REACH Institute, New York, NY, USA Mayo Clinic, Rochester, MN, USA
| | - Daniel F Connor
- University of Connecticut School of Medicine, Farmington, USA
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Martinez-Raga J, Knecht C, de Alvaro R. Profile of guanfacine extended release and its potential in the treatment of attention-deficit hyperactivity disorder. Neuropsychiatr Dis Treat 2015; 11:1359-70. [PMID: 26064054 PMCID: PMC4455846 DOI: 10.2147/ndt.s65735] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The α2-adrenergic receptor agonist guanfacine, in its extended-release formulation (GXR), is the most recent nonstimulant medication approved in several countries for the treatment of attention-deficit hyperactivity disorder (ADHD) as monotherapy and as adjunctive pharmacotherapy to stimulants in children and adolescents. The present paper aims to review comprehensively and critically the pharmacodynamic and pharmacokinetic characteristics and the published evidence on the efficacy and safety profile of GXR in the treatment of ADHD. A comprehensive search of relevant databases (PubMed, Embase, and PsycInfo) was conducted to identify studies published in peer-reviewed journals until January 15, 2015. Though the precise mechanism of action of guanfacine in the treatment of ADHD is not fully understood, it is thought to act directly by enhancing noradrenaline functioning via α2A-adrenoceptors in the prefrontal cortex. Weight-adjusted doses should be used, with a dosing regime on a milligram per kilogram basis, starting at doses in the range 0.05-0.08 mg/kg/day, up to 0.12 mg/kg/day. As evidenced in short-term randomized controlled trials and in long-term open-label extension studies, GXR has been shown to be effective as monotherapy in the treatment of ADHD. Furthermore, GXR has also been found to be effective as adjunctive therapy to stimulant medications in patients with suboptimal responses to stimulants. Many of the adverse reactions associated with GXR, particularly sedation-related effects, were dose-related, transient, mild to moderate in severity, and did not interfere with attention or overall efficacy. There are no reports of serious cardiovascular adverse events associated with GXR alone or in combination with psychostimulants.
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Affiliation(s)
- Jose Martinez-Raga
- Teaching Unit of Psychiatry and Psychological Medicine, University Hospital Doctor Peset, University of Valencia, Valencia, Spain ; CEU Cardenal Herrera University, Valencia, Spain
| | - Carlos Knecht
- Área de Salud Mental, Hospital Padre Jofré, Valencia, Spain
| | - Raquel de Alvaro
- Hospital General, Consorcio Hospitalario Provincial, Castellon, Spain
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20
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Findling RL, McBurnett K, White C, Youcha S. Guanfacine extended release adjunctive to a psychostimulant in the treatment of comorbid oppositional symptoms in children and adolescents with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol 2014; 24:245-52. [PMID: 24945085 PMCID: PMC4064735 DOI: 10.1089/cap.2013.0103] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE The purpose of this study was to assess the effect of guanfacine extended release (GXR) adjunctive to a psychostimulant on oppositional symptoms in children and adolescents with attention-deficit/hyperactivity disorder (ADHD). METHODS A multicenter, double-blind, placebo-controlled dose-optimization study of GXR (1-4 mg/d) or placebo administered morning (a.m.) or evening (p.m.) adjunctive to psychostimulant was conducted in subjects ages 6-17 with suboptimal response to psychostimulant alone. Suboptimal response was defined as treatment with a stable dose of psychostimulant for ≥4 weeks with ADHD Rating Scale IV total score ≥24 and Clinical Global Impressions-Severity of Illness score ≥3, as well as investigator opinion. Primary efficacy and safety results have been reported previously. Secondary efficacy measures included the oppositional subscale of the Conners' Parent Rating Scale-Revised: Long Form (CPRS-R:L); these are reported herein. RESULTS Significant reductions from baseline to the final on-treatment assessment on the oppositional subscale of the CPRS-R:L were seen with GXR plus psychostimulant compared with placebo plus psychostimulant, both in the overall study population (placebo-adjusted least squares [LS] mean change from baseline to the final on-treatment assessment: GXR a.m.+psychostimulant, -2.4, p=0.001; GXR p.m.+psychostimulant, -2.2, p=0.003) as well as in the subgroup of subjects with significant baseline oppositional symptoms (GXR a.m.+psychostimulant, -3.6, p=0.001; GXR p.m.+psychostimulant, -2.7, p=0.013). Treatment-emergent adverse events were reported by 77.3%, 76.3%, and 63.4% of subjects in the GXR a.m., GXR p.m., and placebo groups, respectively, in the overall study population. CONCLUSIONS GXR adjunctive to a psychostimulant significantly reduced oppositional symptoms compared with placebo plus a psychostimulant in subjects with ADHD and a suboptimal response to psychostimulant alone.
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Affiliation(s)
- Robert L. Findling
- Department of Psychiatry, Johns Hopkins University and the Kennedy Krieger Institute, Baltimore, Maryland
| | - Keith McBurnett
- University of California-San Francisco, San Francisco, California
| | - Carla White
- Shire Decessed. At the time of writing, Basingstoke, United Kingdom
| | - Sharon Youcha
- Drexel University College of Medicine, Philadelphia, Pennsylvania
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Garland AF, Brookman-Frazee L, Gray E. The role of parent characteristics in community-based medication treatment for children with disruptive behavior problems. Community Ment Health J 2013; 49:507-14. [PMID: 22766691 PMCID: PMC3517686 DOI: 10.1007/s10597-012-9514-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 06/21/2012] [Indexed: 11/24/2022]
Abstract
Studies have documented increased psychoactive medication use rates among children, but little is known about what child and/or family characteristics predict medication treatment in community-based care. This study examines the role of parent characteristics in children's medication treatment, while accounting for other potential predictors. Participants included 213 children ages 4-13 with disruptive behavior problems. Medication treatment was assessed by parent report; potential predictors of medication treatment, including child characteristics and parent characteristics (e.g., education level, perceived strain and psychopathology) were assessed at service intake. Over 60 % of children used a psychoactive medication during the 16 month study period (most commonly stimulants). Parent education level and reported strain were significant predictors of children's medication treatment even when accounting for other significant predictors such as child diagnosis, age, race/ethnicity, etc. Results highlight the role that parent characteristics have in accessing community-based medication treatment for children with disruptive behavior problems.
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Affiliation(s)
- Ann F Garland
- Department of Psychiatry, University of California, San Diego, USA.
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22
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Erder MH, Xie J, Signorovitch JE, Chen KS, Hodgkins P, Lu M, Wu EQ, Sikirica V. Cost effectiveness of guanfacine extended-release versus atomoxetine for the treatment of attention-deficit/hyperactivity disorder: application of a matching-adjusted indirect comparison. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2012; 10:381-395. [PMID: 23113551 DOI: 10.1007/bf03261873] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND About 7% of children and adolescents are diagnosed with attention-deficit/hyperactivity disorder (ADHD) in the US. Patients with ADHD who are intolerant of or do not have an optimal response to stimulants often use non-stimulants as alternative therapies. Guanfacine extended-release (GXR) and atomoxetine (ATX) are the only non-stimulants approved by the US Food and Drug Administration for once-daily use in the treatment of children and adolescents with ADHD in the US. ATX has been on the market since 2002 while GXR was recently approved in 2009. To date, there is no comparative effectiveness or cost-effectiveness study comparing the two drugs. OBJECTIVES The aim of this study was to assess the cost effectiveness of GXR versus ATX for the treatment of ADHD in children and adolescents, using the comparative efficacy results from a matching-adjusted indirect comparison (MAIC). METHODS The MAIC method was used to compare the efficacy between GXR (target dose and lower doses) and ATX (target dose) in the absence of head-to-head clinical trials. Individual patients in the GXR trials were weighted such that the summary baseline characteristics and the efficacy of the placebo arm of the GXR trials matched exactly with those from published ATX trials. After weighting, the efficacy (i.e. change in the ADHD rating scale, fourth edition [ADHD-RS-IV] total score from baseline) was compared between each GXR dosing group and the ATX group. The results from the MAIC analyses were used to populate a 1-year Markov model that is used to compare the cost effectiveness of GXR versus ATX from a US third-party payer perspective. Effectiveness outcomes for each treatment group were estimated as the proportion of responders, defined as patients with ≥25% reduction in ADHD-RS-IV total score from baseline, and average quality-adjusted life years (QALYs). Utilities associated with response/non-response and disutilities due to adverse events were applied in the model. Costs included drug and medical service costs and were inflated to 2011 US dollars ($US). Incremental cost/QALY and incremental cost/responder were estimated. Univariate sensitivity analyses were conducted by varying all model parameters, including costs, utilities, and response rate. RESULTS The target dose of GXR was 0.12 mg/kg/day. In match-adjusted populations with balanced baseline characteristics, patients receiving GXR at the dose of 0.09-0.12(p = 0.0016) [DOSAGE ERROR CORRECTED] and 0.075-0.09 mg/kg/day (p = 0.0248) had better efficacy, while those receiving GXR at the dose of 0.046-0.075 mg/kg/day had comparable efficacy (p = 0.0699), compared with patients receiving ATX at the target dose of 1.2 mg/kg/day. In the base case of the cost-effectiveness analysis (CEA), GXR had incremental cost-effectiveness ratios of $US10 637/QALY and $US853/responder, compared with ATX (incremental costs: $US74; incremental effectiveness: 0.007 QALYs and 86 responders per 1000 patients treated). Results of all univariate sensitivity analyses showed that the model results were robust to changes in model inputs. CONCLUSIONS To our knowledge, this is the first application of the novel comparative efficacy method of MAIC to a CEA model. The MAIC results indicate that GXR (0.075-0.12 mg/kg/day) was more effective than ATX (1.2 mg/kg/day) in the trial population. The CEA results indicate that GXR is cost effective compared with ATX for the treatment of ADHD in children and adolescents.
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Signorovitch J, Erder MH, Xie J, Sikirica V, Lu M, Hodgkins PS, Wu EQ. Comparative effectiveness research using matching-adjusted indirect comparison: an application to treatment with guanfacine extended release or atomoxetine in children with attention-deficit/hyperactivity disorder and comorbid oppositional defiant disorde. Pharmacoepidemiol Drug Saf 2012; 21 Suppl 2:130-7. [DOI: 10.1002/pds.3246] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Jipan Xie
- Analysis Group, Inc.; Boston MA United States
| | | | - Mei Lu
- Analysis Group, Inc.; Boston MA United States
| | | | - Eric Q. Wu
- Analysis Group, Inc.; Boston MA United States
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24
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Kohn MR, Tsang TW, Clarke SD. Efficacy and Safety of Atomoxetine in the Treatment of Children and Adolescents with Attention Deficit Hyperactivity Disorder. CLINICAL MEDICINE. PEDIATRICS 2012; 6:95-162. [PMID: 23641171 PMCID: PMC3620814 DOI: 10.4137/cmped.s7868] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Several non-stimulant medications have been used in the treatment of attention deficit hyperactivity disorder (ADHD). Atomoxetine, was introduced in 2002. The safety and efficacy of atomoxetine in the treatment of ADHD for children, adolescents, and adults has been evaluated in over 4000 patients in randomized controlled studies and double blinded studies as well as in recent large longitudinal studies. This paper provides an updated summary of the literature on atomoxetine, particularly in relation to findings on the short- and long-term safety of atomoxetine in children and adolescents arising from recent large longitudinal cohort studies. Information is presented about the efficacy, safety, and tolerability of this medication.
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Affiliation(s)
- Michael R. Kohn
- Centre for Research into Adolescents’ Health (CRASH), The Sydney Children's Hospital Network and Westmead Hospital, Westmead, NSW, Australia
- Brain Dynamics Centre, Westmead Millennium Institute for Medical Research and University of Sydney Medical School—Westmead, Westmead, NSW, Australia
- Department of Psychiatry and Medicine, University of Sydney Medical School—Westmead, NSW, Australia
| | - Tracey W. Tsang
- Brain Dynamics Centre, Westmead Millennium Institute for Medical Research and University of Sydney Medical School—Westmead, Westmead, NSW, Australia
- Department of Psychiatry and Medicine, University of Sydney Medical School—Westmead, NSW, Australia
| | - Simon D. Clarke
- Centre for Research into Adolescents’ Health (CRASH), The Sydney Children's Hospital Network and Westmead Hospital, Westmead, NSW, Australia
- Brain Dynamics Centre, Westmead Millennium Institute for Medical Research and University of Sydney Medical School—Westmead, Westmead, NSW, Australia
- Department of Psychiatry and Medicine, University of Sydney Medical School—Westmead, NSW, Australia
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Kahalley LS, Conklin HM, Tyc VL, Wilson SJ, Hinds PS, Wu S, Xiong X, Hudson MM. ADHD and secondary ADHD criteria fail to identify many at-risk survivors of pediatric ALL and brain tumor. Pediatr Blood Cancer 2011; 57:110-8. [PMID: 21337681 PMCID: PMC3092016 DOI: 10.1002/pbc.22998] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Accepted: 12/02/2010] [Indexed: 11/06/2022]
Abstract
BACKGROUND Post-treatment attention problems experienced by pediatric cancer survivors have been described as similar to symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD) experienced in physically healthy children. Accordingly, the objectives of this study were to: (a) estimate the rate of occurrence of ADHD and secondary ADHD (SADHD) in a sample of pediatric cancer survivors, (b) compare the rate of ADHD/SADHD among survivors to the prevalence of ADHD in the general population, and (c) examine clinical correlates of ADHD/SADHD in this sample. PROCEDURE Survivors of pediatric ALL or brain tumor (n = 100) participated in an assessment of attention including a Computerized Performance Measure [Conners' Continuous Performance test-II (CPT-II)], parent and self-report measures (Conners 3), and a structured diagnostic interview for ADHD and other psychological disorders [Diagnostic Interview for Children and Adolescents-IV (DICA-IV)]. RESULTS Binomial tests revealed that the rate of ADHD/SADHD in our sample (9%) was significantly greater than the lower limits of ADHD prevalence among children in the US (3%; P < 0.001), while no difference was identified compared to the upper limits of ADHD prevalence (7%; P > 0.05). Many additional survivors (>25% of the sample) obtained clinical elevations on Conners 3 scales but did not meet ADHD/SADHD criteria. CONCLUSIONS Attentional deficits experienced by pediatric cancer survivors do not appear to resemble the clinical presentation of ADHD or SADHD. Many survivors with cognitive and behavioral difficulties related to attention were not identified using this diagnostic approach. Findings offer needed clarification to guide researchers and clinicians in conceptualizing, assessing, and intervening on attentional late effects.
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Affiliation(s)
- Lisa S. Kahalley
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston TX
| | - Heather M. Conklin
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN
| | - Vida L. Tyc
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN
| | - Stephanie J. Wilson
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN
| | - Pamela S. Hinds
- Department of Nursing Research and Quality Outcomes, Children's National Medical Center, Washington, DC,Department of Pediatrics, George Washington University, Washington, DC
| | - Shengjie Wu
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Xiaoping Xiong
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Melissa M. Hudson
- Department of Oncology, Division of Cancer Survivorship, St. Jude Children's Research Hospital, Memphis, TN
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Cho S, Lee SI, Yoo H, Song DH, Ahn DH, Shin DW, Yum SY, Walton R, Mendez L. A randomized, open-label assessment of response to various doses of atomoxetine in korean pediatric outpatients with attention-deficit/hyperactivity disorder. Psychiatry Investig 2011; 8:141-8. [PMID: 21852991 PMCID: PMC3149109 DOI: 10.4306/pi.2011.8.2.141] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Revised: 11/17/2010] [Accepted: 12/19/2010] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE This multicenter, randomized, open-label, parallel trial aimed to provide a detailed dose-response profile for atomoxetine in Korean pediatric outpatients with attention-deficit/hyperactivity disorder (ADHD). METHODS Male and female outpatients aged 6-18 years with ADHD meeting symptom severity criteria of 1.5 standard deviations above age and gender norms on the ADHD Rating Scale-IV-Parent: Investigator-Administered and Scored (ADHDRS-IV-Parent: Inv), and a Clinical Global Impression-ADHD-Severity score ≥4 were randomized to atomoxetine (mg/kg/day) 0.2 fixed, 0.5 fixed or 0.5 (7 days), 0.8 (7 days) then 1.2 for 28 days. The primary efficacy measure was change in ADHDRS-IV-Parent: Inv total score after 6 weeks of atomoxetine treatment. RESULTS Of 153 randomized patients, 83.7% were male and mean age was 9.8 (SD±2.4) years. The completion rate was 86.9%. A graded dose response was apparent with mean change in ADHDRS-IV-Parent: Inv total scores of -9.6, -12.3 and -14.5 with atomoxetine 0.2, 0.5 and 1.2 mg/kg/day, respectively (p=0.024 - F-test). Moreover, a greater reduction in ADHD symptoms, as assessed by mean change from baseline to endpoint CGI-S and mean CGI-ADHD-Improvement at endpoint, was also observed with increasing atomoxetine dose. More patients receiving atomoxetine 1.2 mg/kg/day reported ≥1 treatment-emergent adverse event/s (58.3%) compared with 0.5 (40.7%; p=0.11) or 0.2 mg/kg/day (29.4%; p=0.005). These were generally mild to moderate. CONCLUSION Atomoxetine was found to be safe and well tolerated at all doses administered in Korean pediatric ADHD patients, and 1.2 mg/kg/day was an efficacious dose in this population.
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Affiliation(s)
- Soochurl Cho
- Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Korea
| | - Soyoung Irene Lee
- Department of Psychiatry, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Hanik Yoo
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Ho Song
- Department of Psychiatry, Yonsei University Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong-Hyun Ahn
- Department of Psychiatry, Hanyang University Medical Center, Seoul, Korea
| | - Dong Won Shin
- Department of Psychiatry, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sun Young Yum
- Neuroscience Clinical Research, Eli Lilly and Company, Seoul, Korea
| | - Richard Walton
- Intercontinental Information Sciences, Eli Lilly Pty Ltd Sydney, NSW, Australia
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Severity of Children’s ADHD Symptoms and Parenting Stress: A Multiple Mediation Model of Self-Regulation. JOURNAL OF ABNORMAL CHILD PSYCHOLOGY 2011; 39:1073-83. [DOI: 10.1007/s10802-011-9528-0] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Dittmann RW, Schacht A, Helsberg K, Schneider-Fresenius C, Lehmann M, Lehmkuhl G, Wehmeier PM. Atomoxetine versus placebo in children and adolescents with attention-deficit/hyperactivity disorder and comorbid oppositional defiant disorder: a double-blind, randomized, multicenter trial in Germany. J Child Adolesc Psychopharmacol 2011; 21:97-110. [PMID: 21488751 DOI: 10.1089/cap.2009.0111] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES The primary objective of this study was to evaluate the efficacy of atomoxetine (ATX, target dose 1.2 mg/kg daily) on symptoms of oppositional defiant disorder (ODD) in children and adolescents with attention-deficit/hyperactivity disorder (ADHD). A secondary objective was to compare fast versus slow up-titration of ATX. METHODS This was a 3-arm, 9-week, randomized, placebo-controlled, double-blind study in ADHD patients (6-17 years) with comorbid ODD (Diagnostic and Statistical Manual of Mental Disorders, 4th edition [DSM-IV] criteria A-C) or conduct disorder (CD). ATX-treatment arms were as follows-ATX-fast: 7 days 0.5 mg/kg, then 1.2 mg/kg; ATX-slow: 7 days each at 0.5 and 0.8 mg/kg, then 1.2 mg/kg. Primary outcome was the Swanson, Nolan, and Pelham Rating Scale-Revised (SNAP-IV) ODD-score after 9 weeks (Mixed Effects Model for Repeated Measures, ATX-up-titration groups pooled). RESULTS In total, 181 patients were randomized, and 180 evaluated (ATX-fast/ATX-slow/placebo: 60/61/59). Baseline characteristics were comparable (84.4% boys; mean age 11.0 years; DSM-IV: 100% ADHD, 75.6% with combined type, 74.4% ODD, 24.4% CD; SNAP-IV ODD-scores, mean ± standard deviation 15.5 ± 4.35). At week 9, SNAP-IV ODD scores were significantly lower versus placebo in both ATX-groups (least square mean [95% confidence interval]: ATX-fast 8.6 [7.2;9.9]; ATX-slow 9.0 [7.7;10.3]; placebo 12.0 [10.6;13.5]; least square mean, ATX-pooled minus placebo: -3.2 [-5.0, -1.5], effect size: -0.69, p < 0.001). SNAP-IV ADHD-scores, CD symptoms (investigator-rated Attention-Deficit and Disruptive Behavior Disorders Instrument, disruptive behavior), Clinical Global Impressions-Severity, and individual treatment behaviors showed corresponding results. Post-hoc analyses indicated interrelationships between the medication effects on ADHD, ODD, and CD symptom scores. For ATX-slow, time to early dropout was significantly longer versus placebo (Hazard Ratio [95% confidence interval]: 3.57 [1.42;8.94]; p = 0.007). Clinically relevant adverse effects (fatigue, sleep disorders, nausea, and gastrointestinal complaints; weeks 1-3) were reported in 60.0% of ATX-fast, 44.3% of ATX-slow, and 18.6% of placebo group patients. CONCLUSIONS ATX for 9 weeks significantly reduced symptoms of ODD/CD and ADHD; slower ATX-up-titration may be better tolerated.
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Affiliation(s)
- Ralf W Dittmann
- Department of Child and Adolescent Psychiatry, Central Institute of Mental Health, Mannheim, Germany.
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Tsang TW, Kohn MR, Hermens DF, Clarke SD, Clark CR, Efron D, Cranswick N, Lamb C, Williams LM. A randomized controlled trial investigation of a non-stimulant in attention deficit hyperactivity disorder (ACTION): rationale and design. Trials 2011; 12:77. [PMID: 21396130 PMCID: PMC3068100 DOI: 10.1186/1745-6215-12-77] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Accepted: 03/13/2011] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The ACTION study (Attention deficit hyperactivity disorder Controlled Trial Investigation Of a Non-stimulant) is a multi-center, double-blind, randomized cross-over trial of the non-stimulant medication, Atomoxetine, in children and adolescents with attention deficit hyperactivity disorder (ADHD). The primary aims are to examine the efficacy of atomoxetine for improving cognition and emotional function in ADHD and whether any improvements in these outcomes are more pronounced in participants with comorbid anxiety; and to determine if changes in these outcomes after atomoxetine are more reliable than changes in diagnostic symptoms of ADHD. This manuscript will describe the methodology and rationale for the ACTION study. METHODS Children and adolescents aged 6 - 17 y with ADHD will be enrolled. Clinical interview and validated scales will be used to confirm diagnosis and screen for exclusion criteria, which include concurrent stimulant use, and comorbid psychiatric or neurological conditions other than anxiety. Three assessment sessions will be conducted over the 13-week study period: Session 1 (Baseline, pre-treatment), Session 2 (six weeks, atomoxetine or placebo), and Session 3 (13 weeks, cross-over after one-week washout period). The standardized touch-screen battery, "IntegNeuro™", will be used to assess cognitive and emotional function. The primary measure of response will be symptom ratings, while quality of life will be a secondary outcome. Logistic regression will be used to determine predictors of treatment response, while repeated measures of analysis will determine any differences in effect of atomoxetine and placebo. RESULTS The methodology for the ACTION study has been detailed. CONCLUSIONS The ACTION study is the first controlled trial to investigate the efficacy of atomoxetine using objective cognitive and emotional function markers, and whether these objective measures predict outcomes with atomoxetine in ADHD with and without comorbid anxiety. First enrollment was in March 2008. The outcomes of this study will be a significant step towards a 'personalized medicine' (and therefore a more efficient) approach to ADHD treatment. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry ANZCTRN12607000535471.
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Affiliation(s)
- Tracey W Tsang
- Brain Dynamics Centre, Sydney Medical School and Westmead Millennium Institute, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael R Kohn
- Brain Dynamics Centre, Sydney Medical School and Westmead Millennium Institute, Sydney, New South Wales, Australia
- Centre for Research into Adolescents' Health, Department of Adolescent Medicine, Westmead Hospital and The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Daniel F Hermens
- Clinical Research Unit, Brain and Mind Research Institute, University of Sydney, Sydney, Australia
- Previous Address: Brain Dynamics Centre, Sydney Medical School and Westmead Millennium Institute, Sydney, New South Wales, Australia
| | - Simon D Clarke
- Brain Dynamics Centre, Sydney Medical School and Westmead Millennium Institute, Sydney, New South Wales, Australia
- Centre for Research into Adolescents' Health, Department of Adolescent Medicine, Westmead Hospital and The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - C Richard Clark
- Cognitive Neuroscience Laboratory, School of Psychology, Flinders University, Adelaide, South Australia, Australia
- Brain Health Clinics, Adelaide, South Australia, Australia
| | - Daryl Efron
- Department of General Paediatrics, Royal Children's Hospital, Parkville, Melbourne, Victoria, Australia
| | - Noel Cranswick
- Clinical Pharmacology and Australian Paediatric Pharmacology Research Unit, Murdoch Children's Research Institute and Royal Children's Hospital, Parkville, Melbourne, Victoria, Australia
| | - Chris Lamb
- Child Development Unit, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Leanne M Williams
- Brain Dynamics Centre, Sydney Medical School and Westmead Millennium Institute, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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A review of attention-deficit/hyperactivity disorder complicated by symptoms of oppositional defiant disorder or conduct disorder. J Dev Behav Pediatr 2010; 31:427-40. [PMID: 20535081 DOI: 10.1097/dbp.0b013e3181e121bd] [Citation(s) in RCA: 124] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Attention-deficit/hyperactivity disorder (ADHD) is a highly prevalent disorder with significant functional impairment. ADHD is frequently complicated by oppositional symptoms, which are difficult to separate from comorbidity with oppositional defiant disorder, conduct disorder, and aggressive symptoms. This review addresses the impact of oppositional symptoms on ADHD, disease course, functional impairment, clinical management, and treatment response. REVIEW OF CLINICAL EVIDENCE Oppositional defiant disorder or conduct disorder may be comorbid in more than half of ADHD cases and are more common with the combined than with the inattentive ADHD subtype. Comorbid symptoms of oppositional defiant disorder and conduct disorder in patients with ADHD can have a significant impact on the course and prognosis for these patients and may lead to differential treatment response to both behavioral and pharmacologic treatments. IMPACT ON CLINICAL MANAGEMENT Assessment of oppositional symptoms is an essential part of ADHD screening and diagnosis and should include parental, as well as educator, input. Although clinical evidence remains limited, some stimulant and nonstimulant medications have shown effectiveness in treating both core ADHD symptoms and oppositional symptoms. CONCLUSIONS Oppositional symptoms are a key consideration in ADHD management, although the optimum approach to treating ADHD complicated by such symptoms remains unclear. Future research should focus on the efficacy and safety of various behavioral and medication regimens, as well as longitudinal studies to further clarify the relationships between ADHD, oppositional defiant disorder, and conduct disorder.
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Blouin B, Maddeaux C, Stanley Firestone J, van Stralen J. Predicting response of ADHD symptoms to methylphenidate treatment based on comorbid anxiety. J Atten Disord 2010; 13:414-9. [PMID: 19401504 DOI: 10.1177/1087054708326269] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE In this small pilot study, the association of comorbid anxiety with the treatment of ADHD is studied. METHODS Eighteen volunteers from a pediatric clinic are tested for ADHD and anxiety and assessed for behavioral and cognitive ADHD symptomology. Response to methylphenidate as treatment for ADHD symptoms is measured 2 to 3 weeks, and again 4 to 6 weeks following the diagnosis of ADHD. RESULTS Methylphenidate proves effective for treating ADHD symptoms (both behavioral and cognitive). Participants are categorized into two groups, those with ADHD and comorbid anxiety and those with ADHD alone. Behaviorally, no statistically significant differences are seen in response between the two groups; however; cognitively, the non-anxious group improves significantly more than the anxious group. CONCLUSION Although anxiety may not affect behavioral response to stimulant medication in ADHD, it does appear to affect the medication response of more subtle symptoms of cognitive performance in ADHD patients.
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Dell'Agnello G, Maschietto D, Bravaccio C, Calamoneri F, Masi G, Curatolo P, Besana D, Mancini F, Rossi A, Poole L, Escobar R, Zuddas A. Atomoxetine hydrochloride in the treatment of children and adolescents with attention-deficit/hyperactivity disorder and comorbid oppositional defiant disorder: A placebo-controlled Italian study. Eur Neuropsychopharmacol 2009; 19:822-34. [PMID: 19716683 DOI: 10.1016/j.euroneuro.2009.07.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2009] [Revised: 07/02/2009] [Accepted: 07/23/2009] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The primary aim of this study was to assess the efficacy of atomoxetine in improving ADHD and ODD symptoms in paediatric patients with ADHD and comorbid oppositional defiant disorder (ODD), non-responders to previous psychological intervention with parent support. METHODS This was a multicentre, randomised, placebo-controlled trial conducted in patients aged 6-15 years, with ADHD and ODD diagnosed according to the DSM-IV criteria by a structured clinical interview (K-SADS-PL). Only subjects who are non-responders to a 6-week standardized parent training were randomised to atomoxetine (up to 1.2 mg/kg/day) or placebo (in a 3:1 ratio) for the following 8-week double blind phase. RESULTS Only 2 of the 156 patients enrolled for the parent support phase (92.9% of males; mean age: 9.9 years), improved after the parent training program; 139 patients were randomised for entering in the study and 137 were eligible for efficacy analysis. At the end of the randomised double blind phase, the mean changes in the Swanson, Nolan and Pelham Rating Scale-Revised (SNAP-IV) ADHD subscale were -8.1+/-9.2 and -2.0+/-4.7, respectively in the atomoxetine and in the placebo group (p<0.001 between groups); changes in the ODD subscale were -2.7+/-4.1 and -0.3+/-2.6, respectively in the two groups (p=0.001 between groups). The CGI-ADHD-S score decreased in the atomoxetine group (median change at endpoint: -1.0) compared to no changes in the placebo group (p<0.001 between groups). Statistically significant differences between groups, in favour of atomoxetine, were found in the CHIP-CE scores for risk avoidance domain, emotional comfort and individual risk avoidance subdomains. An improvement in all the subscales of Conners Parents (CPRS-R:S) and Teacher (CTRS-R:S) subscales was observed with atomoxetine, except in the cognitive problems subscale in the CTRS-R:S. Only 3 patients treated with atomoxetine discontinued the study due to adverse events. No clinically significant changes of body weight, height and vital signs were observed in both groups. CONCLUSIONS Treatment with atomoxetine of children and adolescents with ADHD and ODD, who did not initially respond to parental support, was associated with improvements in symptoms of ADHD and ODD, and general health status. Atomoxetine was well tolerated.
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Dell'Agnello G, Zuddas A, Masi G, Curatolo P, Besana D, Rossi A. Use of atomoxetine in patients with attention-deficit hyperactivity disorder and co-morbid conditions. CNS Drugs 2009; 23:739-53. [PMID: 19689165 DOI: 10.2165/11314350-000000000-00000] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Attention-deficit hyperactivity disorder (ADHD) is one of the most common neurobehavioural disorders in children. It has been shown that as many as 85% of patients with ADHD have at least one psychiatric co-morbidity, and approximately 60% have at least two. Atomoxetine is a specific, noradrenergic reuptake inhibitor that provides an effective treatment option for patients with ADHD and co-morbid conditions. The efficacy of atomoxetine in treating ADHD appears to be unaffected by the presence of co-morbid conditions. Therapy with atomoxetine has been associated with statistically significant improvements in symptoms of oppositional defiant disorder in most, but not all, studies. Limited data suggest this agent may have potential in improving co-occurring symptoms of anxiety and may be useful in patients with co-morbid conditions such as tics or Tourette's syndrome. The tolerability profile of atomoxetine in patients with ADHD and co-morbid conditions was similar to that of patients with uncomplicated ADHD. Atomoxetine was well tolerated, with adverse events generally mild and transient; the most frequent adverse events in patients with ADHD included abdominal pain, decreased appetite, nausea and vomiting. The favourable safety and efficacy profile of atomoxetine makes it a promising treatment for patients with ADHD and associated co-morbidities.
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Affiliation(s)
- Grazia Dell'Agnello
- Medical Department, Eli Lilly, 50019 Sesto Fiorentino, Florence, Italy. dell'
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Hammerness P, McCarthy K, Mancuso E, Gendron C, Geller D. Atomoxetine for the treatment of attention-deficit/hyperactivity disorder in children and adolescents: a review. Neuropsychiatr Dis Treat 2009; 5:215-26. [PMID: 19557116 PMCID: PMC2695220 DOI: 10.2147/ndt.s3896] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE This review examines and summarizes the pharmacodynamic and pharmacokinetic properties, short- and longer-term efficacy, the moderating effect of comorbid disorders, as well as short- and long-term safety and tolerability of atomoxetine for the treatment of pediatric attention-deficit/hyperactivity disorder (ADHD). METHODS A systematic literature search was performed to review the extant literature on articles pertaining to the pharmacological treatment with atomoxetine in pediatric and/or adolescent ADHD. RESULTS There is an extensive literature on atomoxetine; over 4000 children have participated in clinical trials of atomoxetine, demonstrating its short- and longer-term efficacy. In addition, studies have examined the moderating effect of comorbid disorders on atomoxetine response, as well as atomoxetine's therapeutic potential for other psychiatric conditions. Short- and longer-term safety and tolerability continue to be reported. CONCLUSIONS Atomoxetine is indicated for both acute and maintenance/extended treatment of pediatric ADHD. Clinicians and families must be familiar with atomoxetine's evidence base, including its profile of clinical response and its possible effectiveness in the presence of comorbidity.
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Affiliation(s)
- Paul Hammerness
- Clinical and Research Program in Pediatric Psychopharmacology, Massachusetts General Hospital and Harvard Medical School, Cambridge, MA, USA
| | - Katherine McCarthy
- Clinical and Research Program in Pediatric Psychopharmacology, Massachusetts General Hospital and Harvard Medical School, Cambridge, MA, USA
| | - Elizabeth Mancuso
- Clinical and Research Program in Pediatric Psychopharmacology, Massachusetts General Hospital and Harvard Medical School, Cambridge, MA, USA
| | - Cassandra Gendron
- Clinical and Research Program in Pediatric Psychopharmacology, Massachusetts General Hospital and Harvard Medical School, Cambridge, MA, USA
| | - Daniel Geller
- Clinical and Research Program in Pediatric Psychopharmacology, Massachusetts General Hospital and Harvard Medical School, Cambridge, MA, USA
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Attention-deficit/hyperactivity disorder and comorbid oppositional defiant disorder or conduct disorder. ACTA ACUST UNITED AC 2009. [DOI: 10.1007/s12618-009-0002-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
OBJECTIVE Genetic studies of attention-deficit/hyperactivity disorder (ADHD) generally use discrete DSM-IV subtypes to define diagnostic status. To improve correspondence between phenotypic variance and putative susceptibility genes, multivariate classification methods such as latent class analysis (LCA) have been proposed. The aim of this study was to perform LCA in a sample of 1,010 individuals from a nationwide recruitment of unilineal nuclear families with at least one child with ADHD and another child either affected or clearly unaffected. METHOD LCA models containing one through 10 classes were fitted to data derived from all DSM-IV symptoms for ADHD, oppositional defiant disorder, and conduct disorder (CD), as well as seven items that screen for anxiety and depression from the National Initiative for Children's Healthcare Quality Vanderbilt Assessment Scale for Parents. RESULTS We replicated six to eight statistically significantly distinct clusters, similar to those described in other cross-cultural studies, mostly stable when comorbidities are included. For all age groups, anxiety and depression are strongly related to Inattentive and Combined types. Externalizing symptoms, especially CD, are strongly associated with the Combined type of ADHD. Oppositional defiant disorder symptoms in young children are associated with either conduct disorder or anxiety-related symptoms. CONCLUSIONS Methods such as LCA allow inclusion of information about comorbidities to be quantitatively incorporated into genetic studies. LCA also permits incorporation of milder but still impairing phenotypes than are allowed using the DSM-IV. Such methods may be essential for analyses of large multicenter datasets and relevant for future clinical classifications. This population-based ADHD classification may help resolve the contradictory results presented in molecular genetic studies.
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Banaschewski T, Coghill D, Santosh P, Zuddas A, Asherson P, Buitelaar J, Danckaerts M, Döpfner M, Faraone SV, Rothenberger A, Sergeant J, Steinhausen HC, Sonuga-Barke EJ, Taylor E. Langwirksame Medikamente zur Behandlung der hyperkinetischen Störungen 1bearbeitete deutsche Version von Banaschewski et al., Long-acting medications for the hyperkinetic disorders; Eur Child Adolesc Psychiatry (2006); mit freundlicher Genehmigung des Springer-Verlags. ZEITSCHRIFT FUR KINDER-UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2008; 36:81-94; quiz 94-5. [DOI: 10.1024/1422-4917.36.2.81] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Zusammenfassung: Ein Expertengremium aus mehreren europäischen Ländern hat sämtliche verfügbaren veröffentlichten und unveröffentlichten Studienergebnisse zum Einsatz von langwirksamen Medikamenten bei ADHS und hyperkinetischer Störung analysiert und auf dieser Grundlage Empfehlungen zur praktischen Anwendung dieser Arzneimittel entwickelt: Auf der Grundlage der Analyse wurde gefolgert: (1) Langwirksame Präparate sollten zugelassen sein und eingesetzt werden; (2) Sie sollen kurzwirksame Arzneimittel (aus Kostengründen und wegen der höheren Flexibilität der Dosierung) nicht vollständig ersetzen. Individuelle Therapieoptionen sind erforderlich. (3) Sowohl ATX als auch Stimulanzien mit retardierter Freisetzung sollten zur Verfügung stehen. Zusätzlich werden ausführliche Empfehlungen gegeben, nach welchen Kriterien ein spezifisches Präparat für den individuellen Patienten ausgewählt werden sollte.
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Affiliation(s)
- Tobias Banaschewski
- Klinik für Psychiatrie und Psychotherapie des Kindes- und Jugendalters, Zentralinstitut für Seelische Gesundheit, Mannheim
| | - David Coghill
- Dept. of Psychiatry, University of Dundee, Dundee (SCO), UK
| | - Paramala Santosh
- Dept. of Psychological Medicine, Hospital for Children, Great Ormond Street, London, UK
| | - Alessandro Zuddas
- Pädiatrische Neuropsychiatrie, Abt. f. Neurowissenschaften, Universität Cagliari, Italien
| | - Philip Asherson
- MRC Social Genetic & Developmental Research Centre, Institute of Psychiatry, Kings College London, London, UK
| | - Jan Buitelaar
- Abteilung für Psychiatrie, Akademisches Zentrum für Kinder- und Jugend-Psychiatrie, Nijmegen, Niederlande
| | - Marina Danckaerts
- Abteilung für Kinder- und Jugendpsychiatrie, U. Z. Gasthuisberg, Leuven, Belgien
| | - Manfred Döpfner
- Psychiatrie und Psychotherapie des Kindes- und Jugendalters, Universität Köln, Deutschland
| | - Stephen V. Faraone
- Medical Genetics Research Program and Dept. of Psychiatry and Behavioral Sciences SUNY Upstate Medical University, Syracuse (NY), USA
| | - Aribert Rothenberger
- Abteilung für Kinder- und Jugend-Psychiatrie/Psychotherapie, Universität Göttingen, Göttingen, Deutschland
| | - Joseph Sergeant
- Abteilung für klinische Neuropsychologie, Fakultät für Psychologie und Erziehung, Freie Universität, Amsterdam, Niederlande
| | | | | | - Eric Taylor
- Dept. of Child & Adolescent Psychiatry, Institute of Psychiatry, Kings College London, UK
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Bangs ME, Hazell P, Danckaerts M, Hoare P, Coghill DR, Wehmeier PM, Williams DW, Moore RJ, Levine L. Atomoxetine for the treatment of attention-deficit/hyperactivity disorder and oppositional defiant disorder. Pediatrics 2008; 121:e314-20. [PMID: 18245404 DOI: 10.1542/peds.2006-1880] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE In this study we examined the effectiveness of atomoxetine for the treatment of oppositional defiant disorder comorbid with attention-deficit/hyperactivity disorder. METHODS Patients were aged 6 to 12 years and met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnostic criteria for attention-deficit/hyperactivity disorder with a Swanson, Nolan, and Pelham Rating Scale-Revised attention-deficit/hyperactivity disorder subscale score above age and gender norms; Clinical Global Impressions-Severity Scale score of > or = 4; and Swanson, Nolan, and Pelham Rating Scale-Revised oppositional defiant disorder subscale score of > or = 15. Patients were randomly assigned in a 2:1 ratio to receive 1.2 mg/kg per day of atomoxetine (n = 156) or placebo (n = 70) for 8 weeks. Treatment effect on oppositional defiant disorder and attention-deficit/hyperactivity disorder symptoms was measured by using the investigator-rated Swanson, Nolan, and Pelham Rating Scale-Revised. RESULTS Repeated-measures analysis demonstrated a statistically significant difference favoring atomoxetine over placebo in the reduction of Swanson, Nolan, and Pelham Rating Scale-Revised oppositional defiant disorder total scores. There were significant pairwise treatment differences at weeks 2 and 5 but not at week 8 postbaseline. A last-observation-carried-forward analysis showed Swanson, Nolan, and Pelham Rating Scale-Revised scores at endpoint for the atomoxetine and placebo groups were significantly different for attention-deficit/hyperactivity disorder symptoms but not for oppositional defiant disorder symptoms. Atomoxetine was superior to placebo in a last-observation-carried-forward analysis of Clinical Global Impression-Improvement and Clinical Global Impression-Severity scores. CONCLUSIONS This study confirms previous findings that patients with attention-deficit/hyperactivity disorder and comorbid oppositional defiant disorder show statistically and clinically significant improvement in attention-deficit/hyperactivity disorder symptoms and global clinical functioning when treated with atomoxetine. It remains uncertain, however, whether atomoxetine exerts a specific and enduring effect on oppositional defiant disorder symptoms.
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Affiliation(s)
- Mark E Bangs
- Lilly Research Laboratories, Indianapolis, Indiana 46285, USA.
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Cheng JYW, Chen RYL, Ko JSN, Ng EML. Efficacy and safety of atomoxetine for attention-deficit/hyperactivity disorder in children and adolescents-meta-analysis and meta-regression analysis. Psychopharmacology (Berl) 2007; 194:197-209. [PMID: 17572882 DOI: 10.1007/s00213-007-0840-x] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2007] [Accepted: 05/25/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The objective of this study was to evaluate the efficacy and safety of atomoxetine in children and adolescents. MATERIALS AND METHODS We searched for studies published between 1985 and 2006 through Medline, PubMed, PsychInfo and Cochrane Central Register of Controlled Trials (CENTRAL 2006 Issue 3) using keywords related to atomoxetine and attention-deficit/hyperactivity disorder (ADHD) and scanned though reference lists. We included nine randomized placebo-controlled trials (atomoxetine:placebo = 1,150:678). RESULTS Atomoxetine was superior (p < 0.01) to placebo in reducing ADHD symptoms across different scales (Attention-Deficit/Hyperactivity Disorder Rating Scale-IV, Conners' Parent and Teacher Rating Scales-Revised:Short Form, Clinical Global Impression-Severity) rated by different raters (parent, teacher, clinician). The number-needed-to-treat (NNTs) for treatment response and relapse prevention were 3.43 (95% CI, 2.79-4.45) and 10.30 (95% CI, 5.89-40.62), respectively. High baseline ADHD symptoms (p = 0.02) was associated with greater reduction in ADHD symptoms, whereas male gender (p = 0.02), comorbid oppositional defiant disorder (ODD) status (p = 0.01) and ADHD hyperactive/impulsive subtype (p = 0.01) were associated with smaller reductions. The commonest adverse events were gastrointestinal [appetite decrease, number-needed-to-harm (NNH) = 8.81; abdominal pain, NNH = 22.48; vomiting, NNH = 29.96; dyspepsia, NNH = 49.38] and sleep related (somnolence, NNH = 19.41). Young age (p = 0.03) and high baseline hyperactive/impulsive symptoms (p < 0.01) were associated with more adverse events, whereas ADHD inattentive subtype (p = 0.04) was associated with less adverse events. Quality of life using Child Health Questionnaire (CHQ) improved (p < 0.01) with atomoxetine treatment. Both ADHD and ODD symptoms (p < 0.01) were reduced in comorbid ADHD+ODD, and ODD status was not associated with more adverse events. Efficacy and side effects were not altered by comorbid general anxiety disorder or major depression. CONCLUSIONS Atomoxetine is efficacious in reducing ADHD symptoms. It may have a role in treating comorbid ODD or depression, and probably in comorbid anxiety.
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Affiliation(s)
- Jackie Y W Cheng
- Department of Psychiatry, University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong.
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Gau SSF, Huang YS, Soong WT, Chou MC, Chou WJ, Shang CY, Tseng WL, Allen AJ, Lee P. A randomized, double-blind, placebo-controlled clinical trial on once-daily atomoxetine in Taiwanese children and adolescents with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol 2007; 17:447-60. [PMID: 17822340 DOI: 10.1089/cap.2006.0091] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this study was to assess the efficacy and safety of the once-daily atomoxetine compared with placebo in pediatric patients with attention-deficit/hyperactivity disorder (ADHD) in Taiwan. METHOD The study sample included 106 patients aged 6-16 years who met the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria of ADHD randomly assigned to atomoxetine once daily (n = 72) and placebo once daily (n = 34) in a double-blind, 6-week treatment study. The primary efficacy measure was the total score of the ADHD Rating Scale-IV Parents Version: Investigator Administered and Scored. The secondary efficacy measures included the Clinical Global Impressions--ADHD--Severity and Chinese Conner's Parent and Teacher Rating Scale--Revised: Short Form. Data were analyzed on an intent-to-treat basis and a last-observation-carried-forward approach. RESULTS The two treatment groups did not differ in demographics and baseline measures. Compared to the placebo group, the atomoxetine group showed significantly greater reductions in ADHD-related symptoms according to the ratings of investigators, parents, and teachers. The treatment effect size of the primary efficacy measure was 0.70 at the end of study. Adverse events reported significantly more frequently with atomoxetine were decreased appetite (36.1%) and nausea (16.6%). No drug-related serious adverse event was observed. CONCLUSIONS Once-daily atomoxetine is an effective, well-tolerable, and safe treatment for children and adolescents with ADHD in Taiwan.
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Affiliation(s)
- Susan S F Gau
- Department of Psychiatry, College of Medicine, National Taiwan Universiy, Taipei, Taiwan
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Connor DF. Pharmacological Treatment of ODD Symptoms in ADHD Children: A Brief Review. ACTA ACUST UNITED AC 2007. [DOI: 10.1521/adhd.2007.15.1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Biederman J, Spencer TJ, Newcorn JH, Gao H, Milton DR, Feldman PD, Witte MM. Effect of comorbid symptoms of oppositional defiant disorder on responses to atomoxetine in children with ADHD: a meta-analysis of controlled clinical trial data. Psychopharmacology (Berl) 2007; 190:31-41. [PMID: 17093981 DOI: 10.1007/s00213-006-0565-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2006] [Accepted: 08/14/2006] [Indexed: 01/31/2023]
Abstract
RATIONALE Up to 60% of children with attention-deficit/hyperactivity disorder (ADHD) suffer from comorbid affective or behavioral impairments, the most common condition being oppositional defiant disorder (ODD), which occurs in 40-60% of children with ADHD. OBJECTIVES This post hoc meta-analysis was performed to determine the effect of the presence of comorbid ODD symptoms on clinical outcomes among pediatric and adolescent subjects being treated for ADHD. METHODS Acute-phase data were analyzed from three randomized, double-blind, placebo-controlled studies in outpatients aged 6-16 and meeting the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, criteria for ADHD. Subjects received placebo or atomoxetine (max 1.8 mg/kg/day, daily) for 6-8 weeks. Patients were diagnosed with comorbid ODD on structured diagnostic interview (Schedule for Affective Disorders and Schizophrenia for School-aged Children-Present and Lifetime Versions). RESULTS Of the 512 subjects studied, 158 were diagnosed with comorbid ODD. Relative to placebo, atomoxetine treatment significantly reduced ADHD symptoms in both ODD-comorbid and noncomorbid subjects irrespective of the comorbidity with ODD. ADHD subjects also showed significant improvements from baseline on most of the psychosocial measures of the child health questionnaire irrespective of the comorbidity with ODD. Reduction in ODD symptoms was highly related to the magnitude of ADHD response. CONCLUSIONS Atomoxetine treatment significantly reduced ADHD symptoms in both ODD-comorbid and noncomorbid subjects to similar extents, indicating that the presence of comorbid symptoms of oppositionality does not affect clinical outcomes of treatment of ADHD with atomoxetine.
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Affiliation(s)
- Joseph Biederman
- Pediatric Psychopharmacology Unit, Massachusetts General Hospital/Harvard Medical School, Yawkey Center for Outpatient Care-6A, Boston, MA 02114, USA.
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Abstract
Attention deficit hyperactivity disorder (ADHD) is a common chronic condition with childhood onset that can continue into adulthood. Medication is a fundamental element in the management of this disorder. Atomoxetine is the newest nonstimulant medication approved by the United States Food and Drug Administration (FDA) for the treatment of ADHD. It is the only nonstimulant medication approved by the FDA for treatment of adult ADHD. Atomoxetine is a norepinephrine reuptake inhibitor that selectively inhibits the presynaptic norepinephrine transporter. A growing body of literature supports the use of atomoxetine both in children and adults with ADHD. This paper summarizes information from the literature about atomoxetine, including pharmacokinetics, pharmacodynamics, clinical trials, dosing, and side-effects.
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Banaschewski T, Coghill D, Santosh P, Zuddas A, Asherson P, Buitelaar J, Danckaerts M, Döpfner M, Faraone SV, Rothenberger A, Sergeant J, Steinhausen HC, Sonuga-Barke EJS, Taylor E. Long-acting medications for the hyperkinetic disorders. A systematic review and European treatment guideline. Eur Child Adolesc Psychiatry 2006; 15:476-95. [PMID: 16680409 DOI: 10.1007/s00787-006-0549-0] [Citation(s) in RCA: 251] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2006] [Indexed: 10/24/2022]
Abstract
A systematic review of published and unpublished data on the use of long-acting medications in ADHD and hyperkinetic disorder is reported, giving effect sizes and numbers-to-treat for extended-release stimulant preparations and atomoxetine (ATX). A panel of experts from several European countries used the review to make recommendations about the use of these drugs in practice, and conclusions are reported: (1) Long-acting preparations should be available and used; (2) They should not replace short-acting drugs (which will be the initial treatment for many children for reasons of cost and flexibility of dosing). Individual clinical choice is needed. (3) Both ATX and extended-release preparations of stimulants should be available. The choice will depend upon the circumstances, and detailed recommendations are made.
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Affiliation(s)
- Tobias Banaschewski
- Dept. of Child & Adolescent Psychiatry/Psychotherapy, University of Goettingen, Von-Siebold-Str. 5, 37075 Goettingen, Germany.
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Arnold LE, Aman MG, Cook AM, Witwer AN, Hall KL, Thompson S, Ramadan Y. Atomoxetine for hyperactivity in autism spectrum disorders: placebo-controlled crossover pilot trial. J Am Acad Child Adolesc Psychiatry 2006; 45:1196-1205. [PMID: 17003665 DOI: 10.1097/01.chi.0000231976.28719.2a] [Citation(s) in RCA: 194] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To explore placebo-controlled efficacy and safety of atomoxetine (ATX) for attention-deficit/hyperactivity disorder (ADHD) symptoms in children with autism spectrum disorders (ASD). METHOD Children ages 5 to 15 with ASD and prominent ADHD symptoms were randomly assigned to order in a crossover of clinically titrated ATX and placebo, 6 weeks each, separated by 1-week washout. Slopes for each condition were compared by paired t test. RESULTS In 2004-2005, 12 boys and 4 girls (7 with autistic disorder, 1 Asperger's, 8 pervasive developmental disorder not otherwise specified) all completed at least 3 weeks of each condition. On the primary outcome, the Hyperactivity subscale of the Aberrant Behavior Checklist, ATX was superior to placebo (p =.043, effect size d = 0.90). It was also superior on a 0 to 3 rating of nine DSM-IV ADHD hyperactive/impulsive symptoms (p =.005, d = 1.27), but missed significance on nine inattentive symptoms (p =.053, d= 0.89). Nine subjects responded to ATX, four to placebo (25% improvement on the Hyperactivity subscale plus Clinical Global Impressions-Improvement of 1-2. One was rehospitalized for recurrent violence on ATX. Adverse events were otherwise tolerable, with no tendency to stereotypy. CONCLUSIONS ATX appears safe and effective for treating hyperactivity in some children with autism spectrum disorders. The effect appears as large as in a multisite methylphenidate trial in the same population, with fewer intolerable side effects. Further study in autism spectrum disorders is indicated.
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Affiliation(s)
- L Eugene Arnold
- The authors are with Ohio State University's Nisonger Center, Columbus.
| | - Michael G Aman
- The authors are with Ohio State University's Nisonger Center, Columbus
| | - Amelia M Cook
- The authors are with Ohio State University's Nisonger Center, Columbus
| | - Andrea N Witwer
- The authors are with Ohio State University's Nisonger Center, Columbus
| | - Kristy L Hall
- The authors are with Ohio State University's Nisonger Center, Columbus
| | - Susan Thompson
- The authors are with Ohio State University's Nisonger Center, Columbus
| | - Yaser Ramadan
- The authors are with Ohio State University's Nisonger Center, Columbus
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Abstract
This article first reviews ways to assess children in the justice system who may benefit from psychopharmacologic treatments. Second, it summarizes the emerging understanding of the nature of aggression and violence and the utility of using the schema of reactive ("hot") and proactive ("cold") aggression as a way to consider pharmacologic options. Third, it summarizes the current published studies on the treatment of conduct disorder, which roughly corresponds to the population of children in the juvenile justice system. Finally, it examines the ways that different classes of medications might be considered when approaching juvenile delinquents and the ways that psychopharmacology could be used as part of an overall treatment plan.
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Affiliation(s)
- Marie V Soller
- Stanford University School of Medicine, Palo Alto, CA, USA
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Robertson MM. Attention deficit hyperactivity disorder, tics and Tourette's syndrome: the relationship and treatment implications. A commentary. Eur Child Adolesc Psychiatry 2006; 15:1-11. [PMID: 16514504 DOI: 10.1007/s00787-006-0505-z] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2005] [Indexed: 10/25/2022]
Abstract
Tourette's Syndrome (TS) is now recognised to be a common childhood onset neurodevelopmental disorder. Attention deficit hyperactivity disorder (ADHD) is also a common childhood disorder. There are many cases in which the two disorders are comorbid. The reasons for this are unclear, but the comorbidity does not necessarily point to one genetic cause. Sleep is also often disturbed in individuals with TS and ADHD. The treatment implications of ADHD in the setting of tics or TS are important. Clonidine is suggested as a first line treatment. It was once thought that stimulants were contraindicated in the treatment of ADHD in the setting of TS, whereas it is suggested that they may be safe, but should be used judiciously. In addition, it was once thought that the combination of stimulants and clonidine was contraindicated, but from a large study the combination does appear to be safe. A relatively new medication for ADHD is atomoxetine, and although not documented widely in the setting of tics and TS, it may prove useful in this setting; further research is required. This commentary briefly discusses the comorbidity between TS and ADHD and offers treatment suggestions.
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Affiliation(s)
- Mary M Robertson
- Dept. of Mental Health Sciences, University College London, 2nd Floor, Wolfson Building, 48 Riding House Street, London W1W 7EY, UK.
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