An expert opinion on methylphenidate treatment for attention deficit hyperactivity disorder in pediatric patients with epilepsy

Effect of anti-attention-deficit hyperactivity disorder (ADHD) medication on clinical seizures and sleep EEG: A retrospective study of Japanese children with ADHD

Aims

Patients with attention‐deficit hyperactivity disorder (ADHD) often exhibit basic or paroxysmal wave abnormalities on electroencephalography (EEG). Methylphenidate (MPH), an anti‐ADHD stimulant, has been reported to lower the seizure threshold. However, there have been no reports comparing EEG changes before and after administration of the central nervous system (CNS) stimulant MPH, or atomoxetine (ATX) hydrochloride, a non‐CNS stimulant. In this study, we investigated changes in sleep EEG before and after the administration of ADHD treatment drugs.

Method

With the approval of the ethics committee, the medical records of 28 children with ADHD (23 men and 5 women) who gave consent were retrospectively investigated. The appearance of sudden abnormal waves during a 10‐minute sleep EEG recording was measured in 0.1‐second units, and the duration of these waves was calculated as the paroxysmal index (PI).

Results

Paroxysmal index did not differ significantly between patients who received MPH and those who received ATX. In addition, there were no exacerbations of clinical seizures.

Conclusion

It was concluded that ADHD medications do not have an adverse effect on epileptic seizures or abnormal sleep EEGs.

Patients with attention‐deficit hyperactivity disorder (ADHD) often exhibit basic or paroxysmal wave abnormalities on electroencephalography (EEG). We investigated changes in sleep EEG before and after the administration of ADHD treatment drugs. ADHD medications do not have an adverse effect on epileptic seizures or abnormal sleep EEGs.

Methylphenidate for attention problems in epilepsy patients: Safety and efficacy

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

Does memantine improve memory in subjects with focal-onset epilepsy and memory dysfunction? A randomized, double-blind, placebo-controlled trial

OBJECTIVE

Excitotoxic injury involving N-methyl-d-aspartate (NMDA) receptor hyperactivity contributes to epilepsy-related memory dysfunction (ERMD). Current treatment strategies for ERMD have limited efficacy and fail to target the underlying pathophysiology. The present pilot study evaluated the efficacy of memantine, an NMDA receptor antagonist, for the treatment of ERMD in adults with focal-onset seizures.

METHODS

Subjects underwent cognitive testing at baseline, after a 13-week randomized, parallel-group, double-blinded phase (of memantine titrated to 10 mg bid or placebo), and following a 13-week open-label extension phase (of memantine titrated to 10 mg bid). The selective reminding test (SRT) continuous long-term retrieval (CLTR) score and 7/24 Spatial Recall Test learning score served as the primary outcome measures. Secondary measures included tests of attention span, fluency, visual construction, and response inhibition, as well as assessments of quality of life, depression, sleepiness, and side effects.

RESULTS

Seventeen subjects contributed data to the blinded phase (n = 8 memantine, n = 9 placebo). No significant differences were seen between groups on the primary or secondary outcome measures. Pooled data at the end of the open-label phase from 10 subjects (initially randomized to memantine n = 3 or placebo n = 7) demonstrated statistically significant improvement from baseline in CLTR score, memory-related quality of life, spatial span, and response inhibition. No significant changes were evident in depression, sleepiness, side effects, or seizure frequency throughout the trial.

SIGNIFICANCE

Results demonstrated no significant effect of memantine on cognition when assessed at the end of the blinded period. Pooled data at the end of the open-label phase showed significant improvement over baseline performance in measures of verbal memory, frontal-executive function, and memory-related quality of life. These improvements, however, may be due to practice effects and should be interpreted cautiously. Findings suggest a favorable safety profile of memantine in the setting of epilepsy.

Implementation of psychological clinical trials in epilepsy: Review and guide

The International League Against Epilepsy (ILAE) Neuropsychiatry commission and United States Institute of Medicine report both identified cognitive and psychological comorbidities as a significant issue for individuals with epilepsy, with rates as high as 60%. However, there is a paucity of evidence-based treatments for many psychological conditions (e.g., learning disorders, cognitive disorders, behavioral disorders). Because of inherent challenges in the implementation of psychological therapy trials and specific considerations for the population with epilepsy, the focus of the current review was to provide guidance and recommendations to conduct psychological trials for individuals with epilepsy. Several key areas will be discussed, including selection of patients, trial design, psychological intervention considerations, outcomes and evaluation of results, publication of trial results, and special issues related to pediatric clinical trials. Rigorously designed psychological therapy trials will set the stage for evidence-based practice in the care of individuals with epilepsy, with the goal of improving seizures, side effects, and HRQOL.

Methylphenidate, cognition, and epilepsy: A double-blind, placebo-controlled, single-dose study

OBJECTIVE

To evaluate the potential efficacy of immediate-release methylphenidate (MPH) for treating cognitive deficits in epilepsy.

METHODS

This was a double-blind, randomized, single-dose, 3-period crossover study in patients with epilepsy and chronic cognitive complaints comparing the effects of placebo and MPH 10 and 20 mg given 1 week apart. Cognitive outcome was evaluated on the basis of an omnibus z score calculated from performance on the Conners Continuous Performance Test 3 (ability to discriminate between target and nontarget stimuli [d'] and hit reaction time standard deviation), Symbol-Digit Modalities Test, and Medical College of Georgia Paragraph Memory Test. Adverse events and seizure frequency were monitored. An open-label follow-up is reported elsewhere.

RESULTS

Thirty-five adult patients with epilepsy participated, of whom 31 finished. Demographics included the following: mean age = 35.3 years (range 20-62 years), 13 men and 18 women, and baseline seizure frequency of 2.8 per month. Epilepsy types were focal (n = 24), generalized (n = 6), or unclassified (n = 1). Mean epilepsy duration was 12.5 years. A statistically significant performance benefit was present at both 10-mg (p = 0.030) and 20-mg (p = 0.034) MPH doses. No seizures were associated with either MPH dose. Adverse effects leading to withdrawal included cognitive "fogginess" (n = 1 on 20 mg), anxiety/agitation (n = 1 on 10 mg), and tachycardia (n = 1). One participant was lost to follow-up after one 20-mg dose without side effect.

CONCLUSIONS

This single-dose study suggests that MPH may be effective in ameliorating some cognitive deficits in patients with epilepsy. Additional studies are required.

CLINICALTRIALSGOV IDENTIFIER

NCT02178995.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that single doses of MPH improve cognitive performance on some measures of attention and processing speed in patients with epilepsy and cognitive complaints.

Behavioral disorder in people with an intellectual disability and epilepsy: A report of the Intellectual Disability Task Force of the Neuropsychiatric Commission of ILAE

The management and needs of people with intellectual disability (ID) and epilepsy are well evidenced; less so, the comorbidity of behavioral disorder in this population. "Behavioral disorder" is defined as behaviors that are difficult or disruptive, including stereotypes, difficult or disruptive behavior, aggressive behavior toward other people, behaviors that lead to injury to self or others, and destruction of property. These have an important link to emotional disturbance. This report, produced by the Intellectual Disability Task Force of the Neuropsychiatric Commission of the ILAE, aims to provide a brief review of some key areas of concern regarding behavioral disorder among this population and proposes a range of research and clinical practice recommendations generated by task force members. The areas covered in this report were identified by experts in the field as being of specific relevance to the broad epilepsy community when considering behavioral disorder in persons with epilepsy and ID; they are not intended to be exhaustive. The practice recommendations are based on the authors' review of the limited research in this field combined with their experience supporting this population. These points are not graded but can be seen as expert opinion guiding future research and clinical practice.

Epilepsy and attention-deficit hyperactivity disorder: links, risks, and challenges

Attention-deficit hyperactivity disorder (ADHD) has a prevalence rate of 7%-9% in the general population of children. However, in children with epilepsy, ADHD has been found to be present in 20%-50% of patients. This paper provides a review of ADHD prevalence in pediatric epilepsy populations and reviews data on specific symptom presentation and attention deficits in patients with epilepsy. This paper also reviews evidence-based treatments for ADHD and specifically the treatment of ADHD as a comorbid condition in children with epilepsy.

Speed and complexity characterize attention problems in children with localization-related epilepsy

OBJECTIVE

Children with epilepsy (EPI) have a higher rate of attention-deficit/hyperactivity disorder (ADHD; 28-70%) than typically developing (TD) children (5-10%); however, attention is multidimensional. Thus, we aimed to characterize the profile of attention difficulties in children with epilepsy.

METHODS

Seventy-five children with localization-related epilepsy ages 6-16 years and 75 age-matched controls were evaluated using multimodal, multidimensional measures of attention including direct performance and parent ratings of attention as well as intelligence testing. We assessed group differences across attention measures, determined if parent rating predicted performance on attention measures, and examined if epilepsy characteristics were associated with attention skills.

RESULTS

The EPI group performed worse than the TD group on timed and complex attention aspects of attention (p < 0.05), whereas performance on simple visual and simple auditory attention tasks was comparable. Children with EPI were 12 times as likely as TD children to have clinically elevated symptoms of inattention as rated by parents, but ratings were a weak predictor of attention performance. Earlier age of onset was associated with slower motor speed (p < 0.01), but no other epilepsy-related clinical characteristics were associated with attention skills.

SIGNIFICANCE

This study clarifies the nature of the attention problems in pediatric epilepsy, which may be under-recognized. Children with EPI had difficulty with complex attention and rapid response, not simple attention. As such, they may not exhibit difficulty until later in primary school when demands increase. Parent report with standard ADHD screening tools may under-detect these higher-order attention difficulties. Thus, monitoring through direct neuropsychological performance is recommended.

Methylphenidate improves the quality of life of children and adolescents with ADHD and difficult-to-treat epilepsies

OBJECTIVE

Comorbidity between difficult-to-treat epilepsies and ADHD is frequent and impacts negatively on quality of life. The commonly held (yet poorly substantiated) view that stimulants may worsen seizure control has prevented studies from evaluating the impact of such treatment in this population. Our aim was to study the effect of methylphenidate on the quality of life of children and adolescents with difficult-to-treat epilepsies and comorbid ADHD.

METHODS

The study was an open-label, noncontrolled trial with intention-to-treat analysis following 30 patients for 6months. Subjects received methylphenidate following 3months of baseline, during which antiepileptic drugs (AEDs) were adjusted and epilepsy, ADHD, and quality-of-life variables were assessed. Multivariate regression analysis identified the main variables correlated with outcome.

RESULTS

Only one patient withdrew because of seizure worsening. Following methylphenidate introduction, doses were titrated up to 0.40-0.50mg/kg/day. A marked improvement in quality-of-life scores and a significant reduction in seizure frequency and severity were observed. Female sex, reduction of core ADHD symptoms, and tolerability to adequate doses of methylphenidate were significantly associated with improved quality-of-life scores.

CONCLUSION

These preliminary data suggest that methylphenidate treatment is safe and effective in patients with ADHD and difficult-to-treat epilepsies, positively impacting on quality-of-life scores.

Are children affected by epileptic neuropsychiatric comorbidities?

Childhood-onset epilepsy is associated with psychiatric and cognitive difficulties and with poor social outcomes in adulthood. Some antiepileptic drugs adversely affect behavior in susceptible children with easy-to-control or refractory epilepsies, contributing to a high risk of psychological and psychiatric disturbance. Studies had demonstrated that patients with benign rolandic epilepsy and absence epilepsy had more aggressive behavior, depression, and anxiety disorders than control children. Psychiatric comorbidities are strongly associated with a poor long-term health-related quality of life in childhood-onset epilepsy, which suggests that comprehensive epilepsy care must include screening and long-term treatment for these conditions, even if seizures remit.

Methylphenidate treatment of attention deficit hyperactivity disorder in young people with learning disability and difficult-to-treat epilepsy: evidence of clinical benefit

Purpose

To establish the efficacy and safety of methylphenidate (MPH) treatment for attention deficit hyperactivity disorder (ADHD) in a group of children and young people with learning disability and severe epilepsy.

Methods

This retrospective study systematically reviewed the case notes of all patients treated with methylphenidate (MPH) for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) ADHD at a specialist epilepsy center between 1998 and 2005. Treatment efficacy was ascertained using clinical global impressions (CGI) scores, and safety was indexed by instances of >25% increase in monthly seizure count within 3 months of starting MPH.

Key Findings

Eighteen (18) patients were identified with refractory epilepsies (14 generalized, 4 focal), IQ <70, and ADHD. Male patients predominated (13:5) and ADHD was diagnosed at a median age of 11.5 years (range 6–18 years). With use of a combination of a behavioral management program and MPH 0.3–1 mg/kg/day, ADHD symptoms improved in 61% of patients (11/18; type A intraclass correlation coefficient of CGI 0.85, 95% confidence interval [CI] 0.69–0.94). Daily MPH dose, epilepsy variables, and psychiatric comorbidity did not relate to treatment response across the sample. MPH adverse effects led to treatment cessation in three patients (dysphoria in two, anxiety in one). There was no statistical evidence for a deterioration of seizure control in this group with the use of MPH.

Significance

Methylphenidate with behavioral management was associated with benefit in the management of ADHD in more than half of a group of children with severe epilepsy and additional cognitive impairments. Eighteen percent had significant side effects but no attributable increase in seizures. Methylphenidate is useful in this group and is likely to be under employed.

Drug therapy of attention deficit hyperactivity disorder: current trends

Attention deficit hyperactivity disorder is a developmental disorder with an age onset prior to 7 years. Children with ADHD have significantly lower ability to focus and sustain attention and also score higher on impulsivity and hyperactivity. Stimulants, such as methylphenidate, have remained the mainstay of ADHD treatment for decades with evidence supporting their use. However, recent years have seen emergence of newer drugs and drug delivery systems, like osmotic release oral systems and transdermal patches, to mention a few. The use of nonstimulant drugs like atomoxetine and various other drugs, such as α-agonists, and a few antidepressants, being used in an off-label manner, have added to the pharmacotherapy of ADHD. This review discusses current trends in drug therapy of ADHD and highlights the promise pharmacogenomics may hold in the future.

Efficacy and safety of methylphenidate in treating ADHD symptoms in children and adolescents with uncontrolled seizures: a Brazilian sample study and literature review

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) is observed in 30% of children and adolescents with epilepsy. Recent studies have demonstrated the safety of methylphenidate (MPH) in patients with controlled epilepsy. There are few studies of patients with uncontrolled epilepsy. The goal was to study the efficacy and safety of MPH use in children and adolescents diagnosed with ADHD and uncontrolled epilepsy.

METHODS

We evaluated 24 patients ranging from 7 to 16 years of age who took MPH for 6 months. Inclusion criteria were at least two epileptic seizures in the previous 6 months and a diagnosis of ADHD based on DSM-IV criteria.

CONCLUSION

Patients were classified according to ADHD subtype as follows: 41.7% inattentive type, 37.5% combined, and 20.8% hyperactive/impulsive type; 58.3% had partial epilepsy and 41.7% generalized epilepsy. There was an overall improvement in ADHD symptoms in 70.8% of patients, and there was no increase in frequency of epileptic seizures in 22 patients (91.6%).

Clinical response to methylphenidate in a patient with self-induced photosensitive epilepsy

The classification of epilepsy includes a group of generalized idiopathic epilepsies that are triggered by a specific mode of activation, known as reflex epilepsies. Photosensitive epilepsy is the most common type. Some patients with photosensitive epilepsy use this sensitivity to induce seizures or epileptiform discharges on the electroencephalogram. In some patients, psychopharmacological treatment, for instance with selective serotonin reuptake inhibitors and neuroleptics, has demonstrated benefit insofar as self-induction of seizures is concerned. However, so far as we know, there are no documented cases of treatment with methylphenidate in patients with this type of seizure. Our purpose is to report the case of an 8-year-old girl with attention-deficit hyperactivity disorder (ADHD) and self-induced photosensitive epilepsy whose behavior in general, and self-inducing behavior in particular, improved dramatically following treatment with methylphenidate.

Attention deficit and hyperactivity disorder in people with epilepsy: diagnosis and implications to the treatment

The association between attention deficit and hyperactivity disorder (ADHD) and epilepsy can cause significant impact on the social life of affected individuals and their families. Clinical studies suggest that 30-40% of people with epilepsy also have ADHD. There are no studies which demonstrate that short or long-term treatment with methylphenidate increases the risk of seizures. Some studies attempt to relate drug interactions between methylphenidate and antiepileptic drugs, but adverse effects of methylphenidate have not been shown clearly. This review presents some neurobiological and physiopathogenic aspects, common to ADHD and epilepsy, from recent research studies, related to pharmacology, neuroimaging and electroencephalography. Possible risk of occurrence of seizures associated with the use of methylphenidate are also discussed.

Adaptive phase I study of OROS methylphenidate treatment of attention deficit hyperactivity disorder with epilepsy

OBJECTIVE

The goal of this study was to pilot a randomized controlled trial of OROS methylphenidate (OROS-MPH) to treat attention deficit hyperactivity disorder (ADHD) plus epilepsy.

METHODS

Thirty-three patients, 6-18years of age, taking antiepileptic drugs and with a last seizure 1-60months prior were assigned to a maximum daily dose of 18, 36, or 54mg of OROS-MPH in a double-blind placebo-controlled crossover trial.

RESULTS

There were no serious adverse events and no carryover effects in the crossover trial. OROS-MPH reduced ADHD symptoms more than did placebo treatment. There were too few seizures during the active (5) and placebo arms (3) to confidently assess seizure risk; however, considering exposure time, we observed an increased daily risk of seizures with increasing dose of OROS-MPH, suggesting that potential safety concerns require further study.

CONCLUSION

A larger study to assess the effect of OROS-MPH on seizure risk is needed. A crossover design including subjects with frequent seizures could maximize power and address high patient heterogeneity and recruitment difficulties.

Autism spectrum disorders in tuberous sclerosis: pathogenetic pathways and implications for treatment

Autism spectrum disorders have been reported as being much more frequent in individuals with tuberous sclerosis than in the general population. Previous studies have implicated early seizure onset and the localization of cortical tubers in the temporal lobes as risk factors for autism. However, the underlying reasons for this association remain largely unclear. The dysregulation of intracellular signaling through the activation of mTOR pathway could play a direct role in determining susceptibility to autism. Early control of seizures and an early intensive behavioral intervention of autism during the period of brain plasticity can mitigate, but not reverse the final outcome. A greater understanding of the pathogenetic mechanisms underlying autism in tuberous sclerosis could help in devising targeted and potentially more effective treatment strategies.

Association between attention-deficit/hyperactivity disorder and epilepsy in pediatric populations

There is a bidirectional relationship between attention-deficit/hyperactivity disorder (ADHD) and epilepsy. ADHD increases seizure risk, while patients with epilepsy have an increased prevalence of ADHD. The reasons explaining this association are not fully understood. Proposed mechanisms include effects of antiepileptic medications, underlying neurodevelopmental vulnerability, the effects of chronic seizures and subclinical epileptiform activity on cognitive functions and adrenergic dysfunction. There may also be a common genetic defect underlying both disorders in some families. Antiepileptics associated with ADHD-like side effects include phenobarbital, gabapentin, vigabatrin and topiramate. Methylphenidate has been studied in a double-blind setting against placebo for treatment of ADHD comorbid with epilepsy, and has a good risk-benefit ratio. Amphetamine, atomoxetine, clonidine and guanfacine only have case series to support their use and bupropion should be avoided.

Possíveis interfaces entre TDAH e epilepsia

OBJETIVO: Identificar na literatura elementos para explicar uma possível associação entre o transtorno de déficit de atenção e hiperatividade (TDAH) e a epilepsia e orientar quanto ao manejo clínico dos pacientes que compartilham esses transtornos. MÉTODOS: Realizou-se revisão da literatura dos últimos 10 anos nas bases de dados MedLine e Lilacs com a combinação dos descritores "attention deficit hyperactivity disorder", "ADHD" e "epilepsy". RESULTADOS: Sintomas de TDAH são frequentes em síndromes epilépticas idiopáticas. Vários fatores podem contribuir para a coexistência desses transtornos: 1) possibilidade de uma mesma propensão genética; 2) participação dos neurotransmissores noradrenalina e dopamina no TDAH e na modulação da excitabilidade neuronal; 3) anormalidades estruturais do cérebro evidenciadas em epilépticos portadores de TDAH; 4) influência dos efeitos crônicos das crises e das descargas epileptiformes interictais sob a atenção; 5) efeitos adversos das drogas antiepilépticas sob a cognição. CONCLUSÕES: As evidências atuais apontam que crises epilépticas e TDAH podem apresentar bases neurobiológicas comuns. Estudos que avaliam disfunções nas vias de sinalização das catecolaminas cerebrais e o papel das descargas epileptiformes interictais na geração dos sintomas são fundamentais na investigação desses mecanismos. Drogas psicoestimulantes são seguras e eficazes para o tratamento do TDAH na maioria dos portadores de epilepsia.

Attention deficit hyperactivity disorder in children with epilepsy

Attention deficit hyperactivity disorder (ADHD) is more frequent in children with epilepsy than in general pediatric population. Several factors may contribute to this comorbidity, including the underlying brain pathology, the chronic effects of seizures and of the epileptiform EEG discharges, and the effects of antiepileptic drugs. Symptoms of ADHD are more common in some specific types of epilepsies, such as frontal lobe epilepsy, childhood absence epilepsy and Rolandic epilepsy, and may antedate seizure onset in a significant proportion of cases. In epileptic children with symptoms of ADHD, treatment might become a challenge for child neurologists, who are forced to prescribe drugs combinations, to improve the long-term cognitive and behavioral prognosis. Treatment with psychotropic drugs can be initiated safely in most children with epilepsy and ADHD symptoms.

Efficacy and safety limitations of attention-deficit hyperactivity disorder pharmacotherapy in children and adults

There have been major advances in the treatment and understanding of attention-deficit hyperactivity disorder (ADHD) in the last decade. Among these are the availability of newer stimulant formulations, an appreciation of the combined effects of medication and behavioural therapies, and a better understanding of the neurobiology of the disorder in children (aged 6-12 years), adolescents and adults. This article focuses on the evaluation of the efficacy and safety profiles of medications used for the management of ADHD. In assessing the various medical treatments for ADHD, certain issues and analyses have become important to address. The diagnosis, characterization and quantification of ADHD symptoms are crucial to assessing treatment effectiveness. A standardized setting for measuring the severity of ADHD symptoms is the laboratory school protocol, which simulates a school environment with tightly controlled timing of measurements. This method has been adapted successfully to the adult workplace environment to help with the evaluation of adult ADHD symptoms. Statistical analyses, such as effect size and number needed to treat, may aid in the comparison and interpretation of ADHD study results. Although an objective approach to evaluating the efficacy and safety profiles of the available medications provides necessary details about the medical options, typical clinical decisions are often based on trial and error and may be individualized based on a patient's daily routine, comorbidities and risk factors. Stimulants remain the US FDA-approved medical treatment of choice for patients with ADHD and are associated with an exceptional response rate. Findings of the Multimodal Treatment of Children With ADHD study suggest that the combination of behavioural and medical therapy may benefit most patients. Nonstimulant agents, such as atomoxetine (FDA-approved), and several non-approved agents, bupropion, guanfacine and clonidine, may offer necessary alternatives to the stimulants. This is especially important for patients who have comorbidities that are contraindicated for stimulant use based on medical issues and/or risk for stimulant abuse. Typical psychiatric comorbidities in patients with ADHD include oppositional defiant disorder, conduct disorder, major depressive disorder, bipolar disorder, anxiety, substance abuse disorder, tic disorder, and Tourette's syndrome. Although relatively safe, both stimulants and atomoxetine have class-related warnings and contraindications and are associated with adverse effects that require consideration when prescribing. Polypharmacy is a common psychiatric approach to address multiple symptoms or emergent adverse effects of necessary treatments. Future research may provide an improved understanding of polypharmacy and better characterization of the factors that influence the diagnosis and successful treatment of patients with ADHD.

Attention-deficit hyperactivity disorder (ADHD) and tuberous sclerosis complex

The neurobiological basis of attention-deficit hyperactivity disorder (ADHD) in tuberous sclerosis complex is still largely unknown. Cortical tubers may disrupt several brain networks that control different types of attention. Frontal lobe dysfunction due to seizures or epileptiform electroencephalographic discharges may perturb the development of brain systems that underpin attentional and hyperactive functions during a critical early stage of brain maturation. Comorbidity of attention-deficit hyperactivity disorder (ADHD) with mental retardation and autism spectrum disorders is frequent in children with tuberous sclerosis. Attention-deficit hyperactivity disorder (ADHD) may also reflect a direct effect of the abnormal genetic program. Treatment of children with tuberous sclerosis complex with combined symptoms of attention-deficit hyperactivity disorder (ADHD) and epilepsy may represent a challenge for clinicians, because antiepileptic therapy and drugs used to treat attention-deficit hyperactivity disorder (ADHD) may aggravate the clinical picture of each other.

Attention-deficit disorders and epilepsy in childhood: incidence, causative relations and treatment possibilities

At least 20% of children with epilepsy have clinical attention-deficit hyperactivity disorder (ADHD) compared to 3% to 7% of the general pediatric population. Several mechanisms may account for the high prevalence, such as a common genetic propensity, noradrenergic system dysregulation, subclinical epileptiform discharges, or even seizures, antiepileptic drug effects, and psychosocial factors. At the same time, children with attention-deficit hyperactivity disorder have a higher than normal rate of electroencephalography abnormalities (5.6-30.1% vs. 3.5%). Methylphenidate treatment is equally efficient in children with isolated attention-deficit hyperactivity disorder and in children with attention-deficit hyperactivity disorder and epilepsy (70%-77%). Electroencephalography screening in patients with attention-deficit hyperactivity disorder in the absence of other clinical indications or before starting methylphenidate treatment is not currently indicated. Methylphenidate is considered safe for use in children who are seizure-free. However, the few reports of seizure aggravation in methylphenidate-treated children with uncontrolled epilepsy have raised concern.

Methylphenidate for the treatment of depressive symptoms, including fatigue and apathy, in medically ill older adults and terminally ill adults

BACKGROUND

Depressive symptoms, fatigue, and apathy are common symptoms among medically ill older adults and patients with advanced disease, and have been associated with morbidity and mortality. Methylphenidate has been used to treat these symptoms because of its rapid effect. Despite the long history of methylphenidate use for the treatment of depressive symptoms, fatigue, and apathy, there is little definitive evidence to support its use.

OBJECTIVE

The aim of this paper was to review the efficacy and tolerability of methylphenidate in the treatment of depressive symptoms, fatigue, and apathy in medically ill older adults and adults receiving palliative care.

METHODS

English-language articles presenting systematic reviews, clinical trials, or case series describing the use of methylphenidate for the treatment of depressive symptoms, fatigue, or apathy in medically ill older adults or adults receiving palliative care were identified. The key words methylphenidate and either depressive, depression, fatigue, or apathy were used to search the Cochrane Database, MEDLINE, PsycINFO, and International Pharmaceutical Abstracts. Included articles addressed depressive symptoms, fatigue, or apathy in (1) older adults (generally, age > or =65 years), particularly those with comorbid medical illness; (2) adults receiving palliative care; and (3) adults with other chronic illnesses. I excluded articles regarding treatment of depression in healthy young adults; bipolar disorder and attention-deficit/hyperactivity disorder; and narcolepsy, chronic fatigue syndrome, and related disorders.

RESULTS

A total of 19 controlled trials of methylphenidate in medically ill older adults or patients in palliative care were identified. Unfortunately, their conflicting results, small sample sizes, and poor methodologic quality limited the ability to draw inferences regarding the efficacy of methylphenidate, although evidence of tolerability was stronger. The available evidence suggests possible effectiveness of methylphenidate for depressive symptoms, fatigue, and apathy in various medically ill populations.

CONCLUSION

In the absence of definitive evidence of effectiveness, trials of low-dose methylphenidate in medically ill adults with depression, fatigue, or apathy, with monitoring for response and adverse effects, are appropriate.