Innovations and recent trends in the treatment of ADHD

Galantamine efficacy and tolerability as an augmentative therapy in autistic children: A randomized, double-blind, placebo-controlled trial

The role of cholinergic abnormalities in autism was recently evidenced and there is a growing interest in cholinergic modulation, emerging for targeting autistic symptoms. Galantamine is an acetylcholinesterase inhibitor and an allosteric potentiator of nicotinic receptors. This study aimed to evaluate the possible effects of galantamine as an augmentative therapy to risperidone, in autistic children. In this randomized, double-blind, placebo-controlled, parallel-group study, 40 outpatients aged 4-12 years whom had a diagnosis of autism (DSM IV-TR) and a score of 12 or higher on the Aberrant Behavior Checklist-Community (ABC-C) Irritability subscale were equally randomized to receive either galantamine (up to 24 mg/day) or placebo, in addition to risperidone (up to 2 mg/day), for 10 weeks. We rated participants by ABC-C and a side effects checklist, at baseline and at weeks 5 and 10. By the study endpoint, the galantamine-treated patients showed significantly greater improvement in the Irritability (P = 0.017) and Lethargy/Social Withdrawal (P = 0.005) subscales than the placebo group. The difference between the two groups in the frequency of side effects was not significant. In conclusion, galantamine augmentation was shown to be a relatively effective and safe augmentative strategy for alleviating some of the autism-related symptoms.

Pharmacotherapy of pediatric attention-deficit/hyperactivity disorder

This article describes the practical use of available attention-deficit/hyperactivity disorder (ADHD) pharmacotherapies, their formulations and durations of action, and the extent of Food and Drug Administration approvals. It provides data on short-term and long-term safety of these medications, their use in ADHD with comorbid conditions, and strategies for formulating individualized, effective, and well-tolerated pharmacotherapy treatment plans. A clinical vignette focusing on a male child with ADHD is presented. Summaries are presented of ADHD pharmacotherapies and Food and Drug Administration approval status, atomoxetine and stimulant comparator trials, adverse effects and ADHD pharmacotherapy, and delivery system and duration of effect.

Substance use disorders in children and adolescents with attention-deficit/hyperactivity disorder: implications for treatment and the role of the primary care physician

OBJECTIVES

Review the association between attention-deficit/hyperactivity disorder (ADHD) and substance use disorder (SUD) in children and adolescents. Discuss treatment implications and the role of the primary care physician in the management of this comorbidity.

DATA SOURCES

Articles published from 1991 to 2007 were identified through a MEDLINE search using the search terms attention-deficit/hyperactivity disorder and substance use disorder.

STUDY SELECTION

Publications cited include reviews of substance use disorders in children and adolescents with ADHD, manuals of diagnostic tests, and 69 studies of substance use disorders in children and adolescents with ADHD. No non-English-language publications were identified.

DATA SYNTHESIS

Recent reports identify SUD in a high proportion of respondents with ADHD and ADHD in a high proportion of respondents with many types of SUD. Factors that appear to increase the risk for SUD include comorbid psychiatric disorders, particularly conduct disorder. Pharmacotherapy for ADHD appears not to increase the risk for subsequent SUD. Guidelines for the evaluation and treatment of patients with comorbid ADHD and SUD are outlined. Psycho-stimulants carry the risk for misuse by both patients and family members through diversion. Although nonstimulants such as atomoxetine have low abuse potential, they appear to be less efficacious than stimulants. Formulations that have the potential to lower the abuse liability of stimulants are being developed. These include a transdermal form of methylphenidate that has been shown to be efficacious in the treatment of ADHD and a prodrug stimulant, lisdexamfetamine, recently approved for the treatment of ADHD. Clinical data indicate that lisdexamfetamine is efficacious, and significantly lower likability scores were seen with lisdexamfetamine than with equivalent oral doses of d-amphetamine sulfate.

CONCLUSIONS

Pharmacotherapy may reduce the risk for SUD in patients with ADHD. Psycho-stimulants remain the first-line therapy for the core symptoms of ADHD. New formulations of pharmacologic agents with a reduced potential for abuse are being developed.

The evidence-based pharmacological treatment of paediatric ADHD

Attention deficit hyperactivity disorder (ADHD) is common in children, adolescents, and adults, with extensive research establishing it as a valid neurobiological disorder. Without intervention, ADHD can result in significant impairment throughout the lifespan for the individuals it afflicts. Fortunately, multiple evidence-based options are available for the treatment of ADHD, including several efficacious pharmacotherapies. The role of medication, including stimulants as well as non-stimulants, is well-documented by an extensive body of literature. Although there may be less enthusiasm for behavioural and other psychosocial interventions as stand-alone treatments for moderate to severe ADHD, they are recommended as first-line treatment for ADHD management in preschool-aged children, for those patients with mild symptoms, and as an adjunct to medication in patients with comorbid disorders or suboptimal responses to pharmacotherapy. When planning treatment for individuals with ADHD, the potential risks associated with the available interventions must be carefully balanced against the risks of not treating, or not treating adequately. The treatment plan must also include ongoing re-assessment of the effectiveness of and the need for continued therapy. Recent practice parameters provide further specific guidance for the evidence-based assessment and treatment of children and adolescents with ADHD.

Review of pediatric attention deficit/hyperactivity disorder for the general psychiatrist

Attention deficit/hyperactivity disorder (ADHD) is a common and impairing psychiatric condition, affecting significant numbers of children and adolescents. General psychiatrists serve, both by choice and out of necessity, in the assessment and treatment of children and adolescents who have ADHD and in the education of patients and their families. For many clinicians, however, there are numerous unanswered questions regarding the diagnosis and therapeutic interventions for ADHD. This article provides general psychiatrists with a practical overview and update on the assessment, diagnosis, and treatment of pediatric ADHD. Background information, recent relevant research, current evidence-based practice guidelines, and tips for clinical practice are reviewed in this article. The information is presented in a question-answer format.

A bibliometric study of international scientific productivity in attention-deficit hyperactivity disorder covering the period 1980-2005

OBJECTIVE

We have carried out a bibliometric analysis of scientific publications related to attention-deficit hyperactivity disorder (ADHD) and its pharmacological treatment over the period 1980-2005.

METHOD

We selected (in EMBASE and MEDLINE databases) documents that contained in their title the descriptors attention deficit hyperactivity disorder, attention deficit disorder, ADHD and ADD. As bibliometric indicators of production and dispersion we applied Price's Law and Bradford's Law, respectively. We also calculated the national participation index (PI) and correlated it with overall PI in biomedical and health sciences, with PI in the discipline of Psychiatry and with the social-health indicators (per capita Gross Domestic Product, number of physicians and total per capita expenditure on health).

RESULTS

We obtained 5,269 original documents (2,325 corresponded to pharmacological therapy). Our results indicate fulfilment of Price's Law, since scientific production on ADHD undergoes exponential growth (correlation coefficient r = 0.9859, vs. r = 0.9011 after linear adjustment). The most widely studied drugs are methylphenidate (1,251 documents). Division into Bradford zones yields a nucleus occupied exclusively by the Journal of the American Academy of Child and Adolescent Psychiatry (500 articles). A total of 866 different journals were employed. Twelve of the first 20 used journals have an Impact Factor > 2. The principal producer country is the United States (PI = 44.2). Only four countries, of the 20 major producers in health sciences, surpass their own PI in the field of Psychiatry (Brazil, China, Spain and the United States). The correlation between PI and total number of physicians for each country situates Canada, Australia, the United States and Israel in the top positions.

CONCLUSION

Productivity on ADHD has undergone exponential growth in the period 1980-2005, without evidence a saturation point.

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

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

Atomoxetine improved response inhibition in adults with attention deficit/hyperactivity disorder

BACKGROUND

Atomoxetine, a highly selective noradrenaline reuptake inhibitor (SNRI), shows efficacy in the treatment of attention-deficit/hyperactivity disorder (ADHD). Compared with psychostimulants, atomoxetine has a distinct mode of brain action and potentially lower addictive potential. Studies have yet to assess whether atomoxetine improves cognition following a single oral dose in ADHD.

METHODS

Twenty-two adults with DSM-IV ADHD were administered a single oral dose of atomoxetine (60 mg) in a placebo-controlled double-blind crossover design. Cognitive effects were assessed using stop-signal, sustained attention, spatial working memory, and set-shifting paradigms. Normative cognitive data from 20 healthy volunteers were collected for comparison.

RESULTS

The ADHD patients under placebo conditions showed response inhibition and working memory deficits compared with healthy volunteers. Atomoxetine treatment in the ADHD patients was associated with shorter stop-signal reaction times and lower numbers of commission errors on the sustained attention task.

CONCLUSIONS

Atomoxetine improved inhibitory control, most likely via noradrenergically mediated augmentation of prefrontal cortex function. These results have implications for understanding the mechanisms by which atomoxetine exerts beneficial clinical effects and suggest novel treatment directions for other disorders of impulsivity.