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

Effect of vigorous-intensity exercise on the working memory and inhibitory control among children with attention deficit hyperactivity disorder: a systematic review and meta-analysis

This study primarily evaluated the effects of vigorous-intensity exercises on working memory and inhibitory control in children with attention deficit hyperactivity disorder (ADHD). Search for eligible studies through four databases, and then proceed with screening. The inclusion criteria are as follows: (1) Children with ADHD; (2) Randomised controlled trial; (3) The intervention group received exercise, while the control group did not perform any exercises as the treatment; (4) Conducted pre- and post-exercise assessments, which include working memory and inhibitory control parameters. Use the Cochrane bias risk assessment tool to evaluate the quality of the selected study. Select standardized mean difference as the appropriate effect scale index, and use Revman 5.4 software to analyze the mean difference. This study was registered in the PROSPERO (CRD42024597510). A total of ten studies fulfilled the inclusion criteria and were selected for the meta-analysis. The included studies involved 367 males and 159 females, where 273 belonged to the exercise group and 253 from the control group. Participants in the exercise group enhanced working memory [0.37 (0.12, 0.63) p < 0.05, I2 = 0%] than the control group. In addition, the results indicated that submaximal intensity exercise improved inhibition regulation levels significantly [- 0.34 (- 0.65, - 0.03), p < 0.05, I2 = 0%]. Based on the systematic meta-analysis results, vigorous-intensity exercises have effective working memory, cognitive function, and motor ability-increasing effects on children with ADHD. Furthermore, Submaximal intensity exercise can effectively improve control inhibition in children with ADHD.

Raynaud Syndrome Associated with Medication for Attention-Deficit/Hyperactivity Disorder: A Systematic Review

BACKGROUND

Raynaud syndrome (RS) is a peripheral vasculopathy characterised be impaired acral perfusion typically manifesting as skin discolouration with pallor, cyanosis and/or erythema, and increased sensitivity to cold. RS may be primary or secondary to systemic disease, lifestyle and environmental factors or medication. RS has been reported with medication to treat ADHD, but we found no recent comprehensive overview of the literature. The aim of this review is to evaluate the evidence in the published literature for Raynaud syndrome associated with medication for ADHD.

METHODS

We systematically searched PubMed and Embase from inception to 12 June 2024 for articles published in English describing cases of RS in individuals treated with stimulant medication, atomoxetine, guanfacine or clonidine. Identified cases were assessed against the Naranjo Adverse Drug Reaction Scale criteria to determine the probability of a causal relationship with the medication.

RESULTS

The initial search identified 197 articles. A total of 61 cases were identified from 15 case reports, 5 case series, 1 retrospective case-control study, and 1 retrospective cohort study. No randomised, controlled studies were identified. Implicated medications included methylphenidate, (dex)amfetamine and, more rarely, atomoxetine. Most cases were mild and resolved within weeks of discontinuation, dose reduction or switch to an alternative medication. A few cases associated with systemic disease were reported, leading to ulceration, gangrene and the need for amputation or revascularisation in some individuals. Assessment of 28 cases using the Naranjo criteria suggested a 'possible' causative role of ADHD medication in 13 cases, a 'probable' role in 13 cases and a 'definite' role in two cases.

CONCLUSIONS

Due to the uncontrolled nature of all but one of the available studies, a causal relationship between medication for ADHD and RS could not be determined reliably. However, in view of the possibility of severe sequelae, albeit in rare cases, routine monitoring for signs of RS is recommended in individuals treated with CNS stimulants or atomoxetine, especially when initiating treatment or increasing the dose. Large database studies in which individuals act as their own controls should be conducted to clarify any association between treatment with these medications and RS, controlling for confounding factors.

Unraveling the Connections: Eating Issues, Microbiome, and Gastrointestinal Symptoms in Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by challenges in social communication, restricted interests, and repetitive behaviors. It is also associated with a high prevalence of eating disorders, gastrointestinal (GI) symptoms, and alterations in gut microbiota composition. One of the most pressing concerns is food selectivity. Various eating disorders, such as food neophobia, avoidant/restrictive food intake disorder (ARFID), specific dietary patterns, and poor-quality diets, are commonly observed in this population, often leading to nutrient deficiencies. Additionally, gastrointestinal problems in children with ASD are linked to imbalances in gut microbiota and immune system dysregulation. The aim of this narrative review is to identify previous associations between the gut-brain axis and gastrointestinal problems in ASD. We discuss the impact of the "microbiome-gut-brain axis", a bidirectional connection between gut microbiota and brain function, on the development and symptoms of ASD. In gastrointestinal problems associated with ASD, a 'vicious cycle' may play a significant role: ASD symptoms contribute to the prevalence of ARFID, which in turn leads to microbiota degradation, ultimately worsening ASD symptoms. Current data suggest a link between gastrointestinal problems in ASD and the microbiota, but the amount of evidence is limited. Further research is needed, targeting the correlation of a patient's microbiota status, dietary habits, and disease course.

Mental health in children with and without ADHD: the role of physical activity and parental nativity

BACKGROUND

Physical activity (PA) can improve mental health, including anxiety/depression, in individuals with attention-deficit/hyperactivity disorder (ADHD) with minimal side effects, unlike pharmacotherapy that can result in significant side effects. However, the influence of PA on mental health among children with ADHD is understudied. Also, immigrants tend to have better mental health, but the influence of parental nativity on children's mental health is unknown. We examined the relationship between PA, parental nativity, and current anxiety/depression among U.S. children with and without ADHD. We also analyzed whether ADHD diagnosis status moderates the relationship between anxiety/depression and PA or parental nativity.

METHODS

We used national annual cross-sectional data from the 2016 to 2021 National Survey of Children's Health to conduct weighted multivariable logistic regression and moderation analyses, with current anxiety/depression status as the outcome variable. The sampling involves selecting households with children and rostering children in the household from each state and the District of Columbia. A parent or caregiver of the selected child completes the surveys. We restricted the analysis to children aged 6-17 years (N = 140,977).

RESULTS

The prevalence of current anxiety/depression was higher in children with ADHD diagnosis (37.34%) than those without ADHD diagnosis (7.42%). Children with ADHD (versus no ADHD) had higher odds of anxiety/depression. Engaging in PA (versus no PA) and having immigrant parents (versus non-immigrant parents) were associated with lower anxiety/depression odds. ADHD diagnosis status significantly moderated the association between anxiety/depression and PA or parental nativity. However, the three-way interaction between ADHD status, parental nativity, and physical activity was not statistically significant. Stratified by ADHD diagnosis status, those who engaged in PA (versus did not) for 1 to 3 days, 4 to 6 days, and daily were less often diagnosed with anxiety/depression disorder among those with or without ADHD, especially children without ADHD. The odds were also lower for children with or without ADHD whose parents were immigrants than children with non-immigrant parents, particularly children without ADHD who had immigrant parents. Parental nativity did not significantly moderate the association between PA and anxiety/depression among children with and without ADHD.

CONCLUSIONS

Physical activity was associated with lower risks of diagnosed with anxiety/depression disorder among children, especially children without ADHD and those with immigrant parents. Considering parental nativity and incorporating personalized PA in ADHD and anxiety/depression management can improve mental illness and ADHD symptoms among children.

Music and movement therapy improves quality of life and attention and associated electroencephalogram changes in patients with attention-deficit/hyperactivity disorder

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder. Treatments for ADHD include pharmacological and nonpharmacological therapy. However, pharmacological treatments have side effects such as poor appetite, sleep disturbance, and headache. Moreover, nonpharmacological treatments are not effective in ameliorating core symptoms and are time-consuming. Hence, developing an alternative and effective treatment without (or with fewer) side effects is crucial. Music therapy has long been used to treat numerous neurological diseases. Although listening to music is beneficial for mood and cognitive functions in patients with ADHD, research on the effects of music and movement therapy in children with ADHD is lacking.

METHODS

The present study investigated the effects of an 8-week music and movement intervention in 13 children with ADHD. The Pediatric Quality of Life Inventory (PedsQL) was used to evaluate changes in participants' quality of life. Conners' Kiddie Continuous Performance Test (K-CPT 2) and the Swanson, Nolan, and Pelham rating scale (SNAP-IV) were used to assess core symptoms. Electroencephalogram (EEG) recordings were analyzed to determine neurophysiological changes.

RESULTS

The results revealed that the participants' quality of life increased significantly after the 8-week intervention. Furthermore, the participants' hit reaction times in the block 1 and block 2 tests of K-CPT 2 decreased significantly after the intervention. EEG analysis demonstrated an increase in alpha power and Higuchi's fractal dimension and a decrease in delta power in certain EEG channels.

CONCLUSION

Our music and movement intervention is a potential alternative and effective tool for ADHD treatment and it can significantly improve patients' quality of life and attention.

Effect of methylphenidate on height in pediatric attention-deficit hyperactivity disorder patients: a systematic review and meta-analysis

Methylphenidate (MPH), a first-line treatment for attention-deficit hyperactivity disorder (ADHD) management, has been the focus of debate for decades regarding its effect on growth. The aim of this PRISMA meta-analysis was to determine the effect of MPH on height in children/adolescents with ADHD and its predictive factors based on literature reports. Available full-text articles were systematically reviewed to identify clinical studies of pediatric ADHD patients with height Z-score (HZS) data for monotherapy MPH-treated and non-treated groups. We estimated standardized mean differences (SMDs) of HZS or its changes from baseline (ΔHZS) between groups, then identified associated factors through subgroup analyses and meta-regression. For before-after treatment studies, the paired standard errors of ΔHZS were re-estimated to demonstrate in the forest plot. Risk of bias was analyzed using the Newcastle-Ottawa Scale. Among the 29 eligible studies, 26 reported ΔHZS with self-control groups, and ΔHZS or absolute HZS were compared to other external controls in 11 studies. A significant reduction was observed between post-MHP and pre-MPH use, with high heterogeneity (SMD =  - 0.40; 95% confidence interval = [ - 0.54,  - 0.27]; I2 = 91%). The study region, ADHD subtype, and stimulant-naïve status of patients at baseline may modify the effect on HZS. Because of the high clinical heterogeneity in observational studies, clinicians should consider the negative effect of MPH on height in ADHD patients by determining whether patients fulfill appropriate high-risk criteria. Further well-designed longitudinal studies are required to better quantify this effect, especially with prolonged treatment.

Chatbot-supported psychoeducation in adult attention-deficit hyperactivity disorder: randomised controlled trial

BACKGROUND

Although psychoeducation is generally recommended for the treatment of adult attention-deficit hyperactivity disorder (ADHD), participation in clinical psychoeducation groups is impeded by waiting times and the constrained number of patients who can simultaneously attend a group. Digital psychoeducation attempts are promising, but the rapidly expanding number of apps lack evidence and are mostly limited to only a few implemented interactive elements.

AIMS

To determine the potential of digital, self-guided psychoeducation for adult ADHD, a newly developed interactive chatbot was compared with a previously validated, conventional psychoeducation app.

METHOD

Forty adults with ADHD were randomised, of whom 17 participants in each group completed self-guided psychoeducation based on either a chatbot or conventional psychoeducation app between October 2020 and July 2021. ADHD core symptoms were assessed before and after the 3-week interventions, using both the blinded observer-rated Integrated Diagnosis of ADHD in Adulthood interview and the self-rated ADHD Self-Assessment Scale (ADHS-SB).

RESULTS

Observer- and patient-rated ADHD symptoms were significantly reduced from pre- to post-intervention (observer-rated: mean difference -6.18, 95% CI -8.06 to -4.29; patient-rated: mean difference -2.82, 95% CI -4.98 to -0.67). However, there were no group × intervention interaction effects that would indicate a stronger therapeutic benefit of one of the interventions. Likewise, administered psychoeducational knowledge quizzes did not show differences between the groups. No adverse events were reported.

CONCLUSIONS

Self-guided psychoeducation based on a chatbot or a conventional app appears similarly effective and safe for improving ADHD core symptoms. Future research should compare additional control interventions and examine patient-related outcomes and usability preferences in detail.

The effectiveness of a single session of mindfulness-based cognitive training on cardiac vagal control and core symptoms in children and adolescents with attention-deficit/hyperactivity disorder (ADHD): a preliminary randomized controlled trial

This study examined the effectiveness of a mindfulness-based intervention (MBI) on Conners' continuous performance test scores (CPTs), cardiac vagal control (CVC) assessed by vagally mediated heart rate variability (HRV), and mood in children and adolescents with ADHD. We conducted a randomized controlled trial (RCT) recruiting 70 children and adolescents (M age 11.03, SD 2.78) with a clinical diagnosis of ADHD, which were allocated to either 1 session of mindfulness cognitive training, or an active control condition and were examined at baseline, post-treatment and 4-week follow-up. See clinicaltrials.gov: NCT04316832. There was a significant main effect of time on the primary outcomes measured by CPT scores of attention-related problems (omission errors, reaction time) and hyperactivity-impulsivity (commission errors). However, time-by-group interaction did not achieve statistical significance for commission errors and hit RT, indicating that the changes over time in these outcomes were not significantly different between the MBI and Control conditions. In addition, there was a significant time-by-group interaction for omission errors. Relative to control, MBI resulted in a small (d = 0.011) non-statistically significant reduction in omission errors post-treatment. Furthermore, there were no significant differences in detectability. Secondary outcomes were CVC and mood. A small treatment effect on CVC (d = 0.37) was observed; there was a slight increase in vagally mediated HRV measure post-treatment. There were no significant differences in mood improvement over time between conditions. One brief session of MBI effectively enhances CVC but does not significantly improve CPT scores of attention-related problems and hyperactivity-impulsivity or mood in children with ADHD.Clinicaltrials.gov: NCT04316832.

State of the Evidence for Use of Psychotropic Medications in School-Age Youth

Psychotropic medications are commonly prescribed to school-aged youth for the management of mental health concerns. This paper describes the current state of evidence for psychotropic medications in school-aged youth. More specifically, the following sections summarize relevant medication research trials and practice parameters pertaining to psychotropic medication prescribing as well as the specific medications indicated for a range of commonly presenting disorders and symptom clusters in school-aged youth. For each of these disorders and symptom clusters, key findings pertaining to the current state of science and practice are highlighted for the purpose of offering patients, clinicians, researchers, and policymakers with nuanced considerations for the role of psychopharmacology within the context of a larger "whole-child" approach to care that relies on the collaboration of providers and services across systems of care to promote optimal child and family health and wellness. The paper concludes with a discussion about supporting the use of medication treatments in schools, including considerations for ensuring effective family-school-health system collaboration to best meet youth mental health needs.

Stratification of responses to tDCS intervention in a healthy pediatric population based on resting-state EEG profiles

Transcranial Direct Current Stimulation (tDCS) is a non-invasive neuromodulation technique with a wide variety of clinical and research applications. As increasingly acknowledged, its effectiveness is subject dependent, which may lead to time consuming and cost ineffective treatment development phases. We propose the combination of electroencephalography (EEG) and unsupervised learning for the stratification and prediction of individual responses to tDCS. A randomized, sham-controlled, double-blind crossover study design was conducted within a clinical trial for the development of pediatric treatments based on tDCS. The tDCS stimulation (sham and active) was applied either in the left dorsolateral prefrontal cortex or in the right inferior frontal gyrus. Following the stimulation session, participants performed 3 cognitive tasks to assess the response to the intervention: the Flanker Task, N-Back Task and Continuous Performance Test (CPT). We used data from 56 healthy children and adolescents to implement an unsupervised clustering approach that stratify participants based on their resting-state EEG spectral features before the tDCS intervention. We then applied a correlational analysis to characterize the clusters of EEG profiles in terms of participant's difference in the behavioral outcome (accuracy and response time) of the cognitive tasks when performed after a tDCS-sham or a tDCS-active session. Better behavioral performance following the active tDCS session compared to the sham tDCS session is considered a positive intervention response, whilst the reverse is considered a negative one. Optimal results in terms of validity measures was obtained for 4 clusters. These results show that specific EEG-based digital phenotypes can be associated to particular responses. While one cluster presents neurotypical EEG activity, the remaining clusters present non-typical EEG characteristics, which seem to be associated with a positive response. Findings suggest that unsupervised machine learning can be successfully used to stratify and eventually predict responses of individuals to a tDCS treatment.

Abnormal functional asymmetry and its behavioural correlates in adults with ADHD: A TMS-EEG study

OBJECTIVES

Abnormal functional brain asymmetry and deficient response inhibition are two core symptoms of attention deficit hyperactivity disorder (ADHD). We investigated whether these symptoms are inter-related and whether they are underlined by altered frontal excitability and by compromised interhemispheric connectivity.

METHODS

We studied these issues in 52 ADHD and 43 non-clinical adults by comparing: (1) stop-signal reaction time (SSRT); (2) frontal asymmetry of the N200 event-related potential component, which is evoked during response inhibition and is lateralised to the right hemisphere; (3) TMS-evoked potential (TEP) in the right frontal hemisphere, which is indicative of local cortical excitability; and (4) frontal right-to-left interhemispheric TMS signal propagation (ISP), which is reversely indicative of interhemispheric connectivity.

RESULTS

Compared to controls, the ADHD group demonstrated elongated SSRT, reduced N200 right-frontal-asymmetry, weaker TEP, and stronger ISP. Moreover, in the ADHD group, N200 right-frontal-asymmetry correlated with SSRT, with TEP, and with symptoms severity. Conversely, no relationship was observed between ISP and N200 right-frontal-asymmetry, and both TEP and ISP were found to be unrelated to SSRT.

CONCLUSIONS

Our results indicate that abnormal frontal asymmetry is related to a key cognitive symptom in ADHD and suggest that it is underlined by reduced right-frontal excitability.

Transcranial Direct Current Stimulation (tDCS) in Pediatric Populations—– Voices from Typically Developing Children and Adolescents and their Parents

Background

Transcranial direct current stimulation (tDCS) is a brain stimulation technique currently being researched as an alternative or complimentary treatment for various neurological disorders. There is little knowledge about experiences of the participants of tDCS clinical research, especially from pediatric studies.

Methods

An interview study with typically developing minors (n = 19, mean age 13,66 years) participating in a tDCS study, and their parents (n = 18) was conducted to explore their views and experiences and inform the ethical analysis.

Results

Children (10–13 years old) and adolescents (14–18 years old) reported good experiences with the stimulation. Next to financial incentives, main motives to participate in the study were curiosity and the possibility to help develop treatments for children affected by neurological disorders. They could also see a potential of using tDCS in a non-medical setting, especially regarding the provision of equal opportunity, e.g. in education. Parents also presented a positive attitude towards tDCS and their children participation in the basic research study. Nevertheless, their understanding of tDCS was rather poor. Even though many of them understood the techniques, they often did not see the link between the (current) lack of side effects and an absence of longitudinal studies. Parents were also cautious about using tDCS for non-medical/enhancement purposes.

Conclusions

The study findings show a need for more transparent information about the state of the art of tDCS, its function and what it might be able to offer, especially considering the good acceptability of tDCS.

ADHD in children and adolescents: Review of current practice of non-pharmacological and behavioural management

Attention deficit Hyperactivity Disorder (ADHD) is the commonest childhood neurodevelopmental disorder, affecting 3 to 9% by school age, and often persists into adulthood. ADHD in children and young people (CYP) has wide ranging multi-modal impacts on the affected CYP, their carers and the society. Co-morbidity with other neurodevelopmental, behavioural and emotional disorders is the rule rather than exception. Pharmacological treatment is not recommended as the sole therapeutic intervention, and several other non-pharmacological interventions have been advocated within a framework of Multi-modal strategy as the norm, to address both the core symptoms as well as the behavioural and other related difficulties. All paediatric professionals need to be familiar with the principles of different modalities of non-pharmacological or behavioural interventions for managing ADHD in CYP. Most published up-to-date evidence for behavioural interventions both for the core ADHD symptoms and other outcome measures are summarized in this article, including the peculiar problems related to their research. The most effective evidence-based strategies for controlling ADHD core symptoms are combination of stimulant medications with Behavioural therapy (BT) or Cognitive behaviour therapy (CBT), as well as group-based parental Psychoeducation. Standalone BT, CBT, Mindfulness, Neurocognitive training and Neurofeedback cannot currently be recommended for controlling core symptoms due to limited evidence. Other Behavioural interventions could lead to improvements in ADHD-related outcomes, including parenting skills, CYP's social skills, academic performance and disruptive behaviours. School-based non-pharmacological interventions have been shown to reduce disruptive behaviours. Executive skills are also significantly improved with use of computer-based Neurocognitive training and regular physical Cardio exercises. It is disappointing that combinations of different types of psychosocial interventions have low efficacy on both the core ADHD symptoms and other related outcomes. The readers are welcome to test their knowledge and learning efficacy through an accompanying quiz.

Gaze-based attention refocusing training in virtual reality for adult attention-deficit/hyperactivity disorder

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is characterized by substantial interindividual heterogeneity that challenges the systematic assessment and treatment. Considering mixed evidence from previous neurofeedback research, we present a novel feedback system that relies on gaze behavior to detect signs of inattention while performing a neuropsychological attention task in a virtual seminar room. More specifically, an audiovisual feedback was given whenever participants averted their gaze from the given task.

METHODS

Eighteen adults with ADHD and 18 healthy controls performed a continuous performance task (CPT) in virtual reality under three counterbalanced conditions in which either gaze-based feedback, sham feedback, or no feedback was provided. In all conditions, phases of high and low virtual distraction alternated. CPT errors and reaction times, proportions of gaze dwell times (e.g., task focus or distraction focus), saccade characteristics, EEG theta/beta ratios, head movements, and an experience sampling of ADHD symptoms were analyzed.

RESULTS

While patients can be discriminated well from healthy controls in that they showed more omission errors, higher reaction times, higher distraction-related dwell times, and more head movements, the feedback did not immediately improve task performance. It was also indicated that sham feedback was rather associated with an aggravation of symptoms in patients.

CONCLUSIONS

Our findings demonstrate sufficient suitability and specificity for this holistic ADHD symptom assessment. Regarding the feedback, a single-session training was insufficient to achieve learning effects based on the proposed metacognitive strategies. Future longitudinal, multi-session trials should conclusively examine the therapeutic efficacy of gaze-based virtual reality attention training in ADHD.

TRIAL REGISTRATION

drks.de (identifier: DRKS00022370).

The role of sociodemographic and clinical factors in the initiation and discontinuation of attention deficit hyperactivity disorder medication among young adults in Sweden

Introduction

Long-term medication use is a recommended treatment for attention-deficit/hyperactivity disorder (ADHD), however, discontinuation is common. Non-medical factors which might influence initiation and discontinuation are understudied. Therefore, we investigated how different sociodemographic factors and comorbidities were associated with the initiation and discontinuation of ADHD medication use among young adults.

Methods and results

We conducted a population-based prospective cohort study using individually linked administrative register data, in which we included all individuals residing in Sweden, between the age of 19 and 29 who were first diagnosed with ADHD between January 2006 and December 2016 (n = 59224). ADHD medication initiation was defined as the first prescription of ADHD medication in the period from 3 months before to 6 months after the cohort entry date. Those who initiated ADHD medication were followed up for medication use until discontinuation, death/emigration, or until 2019. Logistic and Cox regression models were used to investigate the associations between sociodemographics, health-related predictors and initiation, as well as discontinuation. Overall, 48.7% of the 41399 individuals initiated ADHD medication, most often methylphenidate (87%). Among the initiators, 15462 (77%) discontinued medication use during the follow-up (median time: 150 days). After mutually adjusting all other predictors, initiation was positively associated with older age, male sex, higher level of education, and negatively associated with living at home with parents, immigrant status, being unemployed during the year before inclusion, being on disability pension, having autism, substance use, schizophrenia-spectrum disorders, other mental disability/developmental disorders, cardiovascular diseases or previous accidents. Discontinuation was positively associated with being born abroad, living in big cities, being unemployed during the year before inclusion, having cancer, and negatively associated with a higher educational level, having depression, anxiety or stress-related disorder, autism spectrum disorder or diabetes.

Conclusion

Besides medical factors, sociodemographics, such as educational attainment and immigrant status might also play a role in the initiation and discontinuation of ADHD medication use among young adults newly diagnosed with ADHD.

Effects of Mindfulness-Based Interventions in Children and Adolescents with ADHD: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

(1) Objectives: Mindfulness-based interventions have been receiving more attention in research for children with attention deficit hyperactivity disorder (ADHD). This systematic review and meta-analysis was conducted to synthesize the findings of randomized controlled trials of mindfulness-based interventions for children with ADHD. (2) Methods: A systematic review and meta-analysis of studies published in PsycINFO, PubMed, and Google Scholar was completed from the earliest available date until August 2022. (3) Results: The systematic review included 12 studies that met the inclusion criteria, and the meta-analysis included 11 studies. The overall effect sizes were g = 0.77 for ADHD symptoms, g = 0.03 for externalizing behavior problem, g = 0.13 for internalizing behavior problem, g = 0.43 for mindfulness, and g = 0.40 for parental stress for children with ADHD. (4) Conclusion: The results of this systematic review highlight the possible benefits of mindfulness-based interventions for children with ADHD.

Dominance status is associated with a variation in cannabinoid receptor 1 expression and amphetamine reward

The rewarding effects of psychostimulants appear to be distinct between dominant and subordinate individuals. In turn, the endocannabinoid system is an important modulator of drug reward in the nucleus accumbens and medial prefrontal cortex, however the connection with social dominance is yet to be established. Male rats were classified as dominant or subordinate on the basis of their spontaneous agonistic interactions and drug reward was assessed by means of conditioned place preference with amphetamine (AMPH). In addition, the expression of CB1R, CB2R, FAAH1, and DAGLa was quantified from accumbal and cortical tissue samples. Our findings demonstrate that dominant rats required a lesser dose of AMPH to acquire a preference for the drug-associated compartment, thereby suggesting a higher sensitivity to the rewarding effects of AMPH. Furthermore, dominants exhibited a lower expression of CB1R in the medial prefrontal cortex and nucleus accumbens. This study illustrates how CBR1 expression could differentiate the behavioral phenotypes associated to social dominance.

Influence of COMT (rs4680) and DRD2 (rs1076560, rs1800497) Gene Polymorphisms on Safety and Efficacy of Methylphenidate Treatment in Children with Fetal Alcohol Spectrum Disorders

Fetal alcohol spectrum disorders (FASD) in a course of high prenatal alcohol exposure (hPAE) are among the most common causes of developmental disorders. The main reason for pharmacological treatment of FASD children is attention deficit hyperactivity disorder (ADHD), and methylphenidate (MPH) is the drug of choice. The aim of the study was to assess whether children born of hPAE with ADHD, with or without morphological FASD, differ in terms of catechol-O-methyltransferase (COMT) and dopamine receptor D2 (DRD2) gene polymorphisms, and if genetic predisposition affects response and safety of MPH treatment. The polymorphisms of COMT (rs4680) and DRD2 (rs1076560, rs1800497) were analyzed in DNA samples. A borderline significance was found for the correlation between MPH side effects and the G allele of COMT (rs4680) (p = 0.04994) in all ADHD children. No effect of COMT (rs4680) and DRD2 (rs1076560, rs1800497) polymorphisms and the treatment efficacy was observed. The analyzed DRD2 and COMT gene polymorphisms seem to play no role in MPH efficacy in ADHD children with hPAE, while low-activity COMT (Met158) variant carriers may be more intolerant to MPH. The MPH treatment is effective in ADHD independent of FASD, although the ADHD-FASD variant requires higher doses to be successful. These results may help in optimization and individualization in child psychiatry.

Association of the Healthcare Effectiveness Data and Information Set (HEDIS) Follow-Up Care Measures and Medication Adherence Among Medicaid Insured Children with ADHD

OBJECTIVES

To assess the association of HEDIS C&M phase follow-up measure with ADHD medication adherence.

METHODS

A retrospective study was conducted using Medicaid data (2014-2016) of children initiated with ADHD medication. Patients were categorized as meeting the C&M follow-up measure or not according to the HEDIS specifications. Medication adherence was measured using both Proportion of Days Covered (PDC) & Group-Based Trajectory Modeling (GBTM). The association of medication adherence with HEDIS measure was assessed using Chi-square test.

RESULTS

Nearly all (97%) children with PDC≥0.7 and 72% of patients following the late decliner adherence trajectory met the HEDIS C&M follow-up criteria. In contrast, none of the children with PDC<0.7 and only two following rapid and slow decliner trajectories met the criteria.

CONCLUSION

ADHD medication adherence, regardless of how it was measured, clearly differentiated children with and without C&M phase follow-up, which essentially questions the implication of HEDIS C&M phase follow-up care measure.

Dextroamphetamine Treatment in Children With Hypothalamic Obesity

INTRODUCTION

Hypothalamic obesity (HO) in children has severe health consequences. Lifestyle interventions are mostly insufficient and currently no drug treatment is approved for children with HO. Amphetamines are known for their stimulant side-effect on resting energy expenditure (REE) and suppressing of appetite. Earlier case series have shown positive effects of amphetamines on weight in children with acquired HO. We present our experiences with dextroamphetamine treatment in the, up to now, largest cohort of children with HO.

METHODS

A retrospective cohort evaluation was performed of children with HO treated with dextroamphetamine at two academic endocrine pediatric clinics. Off-label use of dextroamphetamine was initiated in patients with progressive, therapy-resistant acquired or congenital HO. Anthropometrics, REE, self-reported (hyperphagic) behavior and energy level, and side effects were assessed at start and during treatment.

RESULTS

Nineteen patients with a mean age of 12.3 ± 4.0 years had been treated with dextroamphetamine. In two patients, ΔBMI SDS could not be evaluated due to short treatment duration or the simultaneous start of extensive lifestyle treatment. Mean treatment duration of the 17 evaluated patients was 23.7 ± 12.7 months. Fourteen patients (n = 10 with acquired HO, n = 4 with congenital HO) responded by BMI decline or BMI stabilization (mean ΔBMI SDS of -0.6 ± 0.8, after a mean period of 22.4 ± 10.5 months). In three patients, BMI SDS increased (mean ΔBMI SDS of +0.5 ± 0.1, after a mean period of 29.7 ± 22.6 months). In 11 responders, measured REE divided by predicted REE increased with +8.9%. Thirteen patients (68.4%) reported decreased hyperphagia, improvement of energy level and/or behavior during treatment. Two patients developed hypertension during treatment, which resulted in dosage adjustment or discontinuation of treatment. Twelve children continued treatment at last moment of follow-up.

CONCLUSION

In addition to supportive lifestyle interventions, dextroamphetamine treatment may improve BMI in children with HO. Furthermore, dextroamphetamines have the potential to decrease hyperphagia and improve resting energy expenditure, behavior, and energy level. In patients with acquired HO, these effects seem to be more pronounced when compared to patients with congenital HO. Future studies are needed to support these results.

Attitudes and practices in the management of attention deficit hyperactivity disorder among Brazilian pediatric neurologists who responded to a national survey: a cross-sectional study

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) has a prevalence of 5.3% among children and adolescents. It is characterized by attention deficit, hyperactivity, and impulsivity.

OBJECTIVE

We aimed to conduct a survey involving pediatric neurologists in the management of ADHD and compare the results with the current literature and guidelines.

DESIGN AND SETTING

Descriptive analytical study of a virtual environment, was used Test of equality of proportions for comparison between two groups of pediatric neurologists (working as specialists for > 6 versus ≤ 6 years), with a significance level of P = 0.05.

METHODS

This cross-sectional study used a virtual questionnaire covering the steps in the diagnosis and treatment of children with ADHD. The inclusion criteria were professionals who had completed their residency/specialization in pediatric neurology and clinical neurologists working in pediatric neurology.

RESULTS

Among the 548 electronic invitations sent, 128 were considered valid. For all participants, the diagnosis was clinically based on the disease classification manuals. Combination treatment promotes improvement of symptoms (96.9%). Among psychostimulants, short-acting methylphenidate was the most commonly prescribed medication (85.2%). Headache was the most common side effect (77.3%). Altogether, 73.4% of the participants requested laboratory tests, 71.1% requested an electrocardiogram, and 42.2% requested an electroencephalogram. Pediatric neurologists working as specialists for ≤ 6 years had more frequent referrals to psycho-pedagogists for diagnosis (P = 0.03).

CONCLUSIONS

The participants complied with clinical guidelines, emphasizing the relevance of diagnostic manuals and treatment guidelines for an eminently clinical situation and enabling uniformity in quality treatment.

The impact of methylphenidate treatment on the functional and structural properties of the left ventricle: A medium-term prospective study

INTRODUCTION

Although methylphenidate (MPH) used for treatment of attention deficit hyperactivity disorder (ADHD) are considered safe in healthy children and adolescents in the short and medium term, there is a widespread concern about long-term cardiovascular safety.

MATERIAL AND METHODS

Interventional, prospective, longitudinal and comparative study with a crossover design to evaluate the cardiovascular impact of the treatment with MPH in healthy children and adolescents diagnosed with ADHD. A protocol for the cardiovascular evaluation was established at a basal point, after the first and the second year of the beginning with treatment based on the monitoring of blood pressure (BP) and echocardiographic follow-up of the systolic and diastolic functions, and structural cardiac properties.

RESULTS

73 patients completed the study, with an average age of 9 ± 2.6 years, 75.3% were male and the majority were thin (64.4%). We found an increase in Systolic and Diastolic BP of 3.7 ± 9 mmHg (P = 0.004) and 2 ± 11,5 mmHg respectively. There were no severe cardiovascular events. We didn't find any echocardiographic alterations namely on the structural properties or parameters of systolic function. Regarding diastolic function, a significant increase in the isovo-lumic relaxation time (IVRT) (P = 0.046) and deceleration time (P = 0.016) was observed. However, no significant alterations in the parameters related to distensibility of the LV neither in the early diastolic pressure were found.

CONCLUSION

Further studies are needed to evaluate the impact of psychostimulants as a modifiable long-term Cardiovascular Risk Factor.

Exploring the Efficacy of a Mindfulness Program for Boys With Attention-Deficit Hyperactivity Disorder and Oppositional Defiant Disorder

Objective: This study was the first attempt to explore the efficacy of a mindfulness protocol for children with attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), and their parents. Method: Fifty male children with ADHD and ODD diagnosis, aged 8 to 12, were randomly assigned to the mindfulness intervention (n = 25) or the wait-list (n = 25) group. Outcome measures included children, parents', and teachers' reports and objective measures of attention. Results: Children from the intervention group had a greater reduction in hyperactive behaviors in the school context (effect size [ES] = 0.59) and a greater improvement in visual sustained attention (ES = 0.77) and in Avoidance and Fusion Questionnaire scores (ES = 0.43) than those in the wait-list control group. No significant effect of the intervention on aggressive behaviors was revealed. Conclusion: A mindfulness intervention for children and their parents showed partial beneficial effects in children with ADHD + ODD.

A randomized-controlled neurofeedback trial in adult attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is a childhood onset disorder persisting into adulthood for a large proportion of cases. Neurofeedback (NF) has shown promising results in children with ADHD, but randomized controlled trials in adults with ADHD are scarce. We aimed to compare slow cortical potential (SCP)- and functional near-infrared spectroscopy (fNIRS) NF to a semi-active electromyography biofeedback (EMG-BF) control condition regarding changes in symptoms and the impact of learning success, as well as changes in neurophysiological parameters in an adult ADHD population. Patients were randomly assigned to SCP-NF (n = 26), fNIRS-NF (n = 21) or EMG-BF (n = 20). Outcome parameters were assessed over 30 training sessions (pre, intermediate, post) and at 6-months follow-up (FU) including 3 booster sessions. EEG was recorded during two auditory Go/NoGo paradigms assessing the P300 and contingent negative variation (CNV). fNIRS measurements were conducted during an n-back- as well as a Go/NoGo task. All three groups showed equally significant symptom improvements suggesting placebo- or non-specific effects on the primary outcome measure. Only when differentiating between learners and non-learners, fNIRS learners displayed stronger reduction of ADHD global scores compared to SCP non-learners at FU, and fNIRS learners showed specifically low impulsivity ratings. 30.8% in the SCP-NF and 61.9% of participants in the fNIRS-NF learned to regulate the respective NF target parameter. We conclude that some adults with ADHD learn to regulate SCP amplitudes and especially prefrontal hemodynamic activity during NF. We did not find any significant differences in outcome between groups when looking at the whole sample. When evaluating learners only, they demonstrate superior effects as compared to non-learners, which suggests specific effects in addition to non-specific effects of NF when learning occurs.

Evidence-based pharmacological treatment options for ADHD in children and adolescents

Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsivity, causing functional impairment. Its prevalence lies at approximately 5% in children and adolescents and at approximately 2.5% in adults. The disorder follows a multifactorial etiology and shows a high heritability. Patients show a high interindividual and intraindividual variability of symptoms, with executive deficits in several cognitive domains. Overall, ADHD is associated with high rates of psychiatric comorbidities, and insufficient treatment is linked to adverse long-term outcomes. Current clinical guidelines recommend an individualized multimodal treatment approach including psychoeducation, pharmacological interventions, and non-pharmacological interventions. Available medications include stimulants (methylphenidate, amphetamines) and non-stimulants (atomoxetine, guanfacine, clonidine). While available pharmacological treatment options for ADHD show relatively large effect sizes (in short-term trials) and overall good tolerability, there is still a need for improvement of current pharmacotherapeutic strategies and for the development of novel medications. This review summarizes available pharmacological treatment options for ADHD in children and adolescents, identifies current issues in research and evidence gaps, and provides an overview of ongoing efforts to develop new medications for the treatment of ADHD in children and adolescents by means of a systematic cross-sectional analysis of the clinical trials registry www.clinicaltrials.gov.

Effects of methylphenidate on blood pressure, QT-interval, and cardiac output in ADHD diagnosed children: A three months' follow-up study

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) is one of the most prevalent psychiatric disorders of childhood. It's been suggested that both the condition and the medications used to treat it can affect the cardiovascular system. This study aims to determine whether methylphenidate has the significant effects in cardiac indices.

METHODS

In this prospective study, 100 newly ADHD-diagnosed children aged 6 to 11 whom all on methylphenidate were included. The demographic, clinical data including the blood pressure and heart rate (HR), echocardiographic, and QT-interval were recorded at baseline and after three months of follow-up.

RESULTS

After the follow-up period, we observed no abnormal systolic, diastolic, or mean arterial pressure in any of the participants based on their age, height, and gender (p < 0.001). However, the mean of all these variables was significantly increased (p 〈0 0 1). Mean pulse pressure was also higher than baseline but it wasn't statistically significant (p = 0.059). No significant change was observed in echocardiographic parameters and QT.

CONCLUSION

Short-term treatment of ADHD in children with methylphenidate does not have a meaningful relationship with hypertension and increased corrected QT interval. However, an increase in blood pressure and corrected QT interval within a non-pathological range suggests that longer follow-ups may reveal an association.

Transcranial direct-current stimulation and pediatric attention deficit hyperactivity disorder (ADHD)-Findings from an interview ethics study with children, adolescents, and their parents

INTRODUCTION

Transcranial direct current stimulation (tDCS) is a brain stimulation technique for an alternative or complementary treatment for various neurological disorders, including pediatric ADHD. However, little is known about the experiences of participants undergoing tDCS treatments in clinical trials. Exploration of their views on the matter is an important contribution to the societal debate on ethical issues of tDCS, allowing for a responsible translation into clinical practice and timely identification of potential challenges.

METHODS

in-depth interviews study with children with ADHD undertaking tDCS and their parents (n=32).

RESULTS

Children reported overall good experiences with the stimulation, although they found participation in the clinical study very tiring and time consuming. Their responses to the actual effects of the stimulation were mixed. Parents were very keen for their children to participate in the study as they saw it as a promising and safe alternative to medication. Even though many of them understood the techniques, they often did not see the link between the (current) lack of side effects and an absence of longitudinal studies. Unlike children, interviewed parents were cautious about using tDCS for non-medical/enhancement purposes.

DISCUSSION

There is a need for more transparent information about the state of the art of tDCS, its function and what it actually might be able to offer. It is especially important in order to prevent unrealistic hopes and to make sure that future pediatric patients and their carers are more aware of the potential side-effects and long-term effects of tDCS.

Sensory processing and P300 event-related potential correlates of stimulant response in children with attention-deficit/hyperactivity disorder: A critical review

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder associated with considerable impairment in psychiatric and functional domains. Although stimulant medication can reduce core symptoms of inattention, hyperactivity, and impulsivity, a subgroup of patients does not respond to this intervention. A precision medicine approach has been proposed, whereby biomarkers are used to identify an effective treatment approach for a given individual. This review synthesizes the existing literature on event-related potential (ERP) correlates of stimulant response in children diagnosed with ADHD, with the goal of evaluating the potential for ERP to inform precision medicine care in this population. Forty-three articles were examined and results tentatively suggest that stimulant medications normalize the amplitude of the P300 component, and this is also associated with behavioral improvement. In contrast, results generally indicate that stimulants do not significantly alter early processing components, although there are some exceptions to this finding. Implications for research, theory, and clinical work are considered and concrete recommendations for future directions are provided. While recognizing limitations of existing literature (e.g., homogenous samples, variable methodologies), we conclude that ERP methods represent a promising approach for precision medicine care of patients with ADHD.

Goal management training for adults with ADHD - clients' experiences with a group-based intervention

BACKGROUND

There is growing evidence for the efficacy of group-based interventions for adults with ADHD. However, there is still a lack of research investigating how clients experience participating in such interventions. The aim of the current study was to explore how adults with ADHD experience participating in a group-based intervention (Goal Management Training) for ADHD.

METHOD

We conducted individual, semi-structured, interviews with ten adults with ADHD who had participated in Goal Management Training administered as a group intervention. The interviews were transcribed verbatim and analyzed using thematic analysis within a hermeneutic phenomenological framework.

RESULTS

Our analysis identified three main themes. The participants' starting point captured the participants' motivation and expectations prior to treatment. The ambiguity of the group - the various meanings of the group consisted of three sub-themes (The group created a sense of belonging - "I am not alone"; The personal cost of participating in the group - "At times it was a hot mess"; and The group supported the learning experience - "We worked with it together"). The group promoted positive change - How the group affected the participants' everyday lives consisted of two sub-themes (Managing ADHD in daily life - "It's much easier to handle everyday life", and Personal growth - "Gaining new perspectives").

CONCLUSION

The group format was experienced as a valuable aspect of treatment. The structure provided by Goal Management Training allowed participants to expand their perspectives and experience improved management of ADHD, as well as personal growth. The opportunity to exchange experiences with others in similar situations was seen as particularly beneficial and brought feelings of recognition and belonging. However, some also experienced the group as a burden at times, for instance by stealing one's focus. This study expands existing knowledge by exploring clients' experiences of participating in group-based interventions for ADHD and shows how the group format provided participants with more than they had hoped for. While expecting a more instrumental outcome of treatment, such as tools to manage ADHD, participants also gained a welcomed, but unexpected outcome of personal growth.

[The impact of methylphenidate treatment on the functional and structural properties of the left ventricle: A medium-term prospective study]

INTRODUCTION

Although methylphenidate (MPH) used for treatment of Attention deficit hyperactivity disorder (ADHD) are considered safe in healthy children and adolescents in the short and medium term, there is a widespread concern about long-term cardiovascular safety.

MATERIAL AND METHODS

Interventional, prospective, longitudinal and comparative study with a crossover design to evaluate the cardiovascular impact of the treatment with MPH in healthy children and adolescents diagnosed with ADHD. A protocol for the cardiovascular evaluation was established at a basal point, after the first and the second year of the beginning with treatment based on the monitoring of Blood pressure (BP) and echocardiographic follow-up of the systolic and diastolic functions, and structural cardiac properties.

RESULTS

73 patients completed the study, with an average age of 9+/- 2.6 years, 75.3% were male and the majority were thin (64.4%). We found an increase in Systolic and Diastolic BP of 3.7±9mmHg (P).004) and 2±11,5mmHg respectively. There were no severe cardiovascular events. We didn't find any echocardiographic alterations namely on the structural properties or parameters of systolic function. Regarding diastolic function, a significant increase in the isovolumic relaxation time (IVRT) (P=.046) and deceleration time (P=.016) was observed. However, no significant alterations in the parameters related to distensibility of the LV neither in the early diastolic pressure were found.

CONCLUSION

Further studies are needed to evaluate the impact of psychostimulants as a modifiable long-term Cardiovascular Risk Factor.

Long term methylphenidate exposure and growth in children and adolescents with ADHD. A systematic review and meta-analysis

BACKGROUND

Methylphenidate (MPH) is an efficacious treatment for ADHD but concerns have been raised about potential adverse effects of extended treatment on growth.

OBJECTIVES

To systematically review the literature, up to December 2018, conducting a meta-analysis of association of long-term (> six months) MPH exposure with height, weight and timing of puberty.

RESULTS

Eighteen studies (ADHD n = 4868) were included in the meta-analysis. MPH was associated with consistent statistically significant pre-post difference for both height (SMD = 0.27, 95% CI 0.16-0.38, p < 0.0001) and weight (SMD = 0.33, 95% CI 0.22-0.44, p < 0.0001) Z scores, with prominent impact on weight during the first 12 months and on height within the first 24-30 months. No significant effects of dose, formulation, age and drug-naïve condition as clinical moderators were found. Data on timing of puberty are currently limited.

CONCLUSIONS

Long-term treatment with MPH can result in reduction in height and weight. However, effect sizes are small with possible minimal clinical impact. Long-term prospective studies may help to clarify the underlying biological drivers and specific mediators and moderators.

Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women

BACKGROUND

There is evidence to suggest that the broad discrepancy in the ratio of males to females with diagnosed ADHD is due, at least in part, to lack of recognition and/or referral bias in females. Studies suggest that females with ADHD present with differences in their profile of symptoms, comorbidity and associated functioning compared with males. This consensus aims to provide a better understanding of females with ADHD in order to improve recognition and referral. Comprehensive assessment and appropriate treatment is hoped to enhance longer-term clinical outcomes and patient wellbeing for females with ADHD.

METHODS

The United Kingdom ADHD Partnership hosted a meeting of experts to discuss symptom presentation, triggers for referral, assessment, treatment and multi-agency liaison for females with ADHD across the lifespan.

RESULTS

A consensus was reached offering practical guidance to support medical and mental health practitioners working with females with ADHD. The potential challenges of working with this patient group were identified, as well as specific barriers that may hinder recognition. These included symptomatic differences, gender biases, comorbidities and the compensatory strategies that may mask or overshadow underlying symptoms of ADHD. Furthermore, we determined the broader needs of these patients and considered how multi-agency liaison may provide the support to meet them.

CONCLUSIONS

This practical approach based upon expert consensus will inform effective identification, treatment and support of girls and women with ADHD. It is important to move away from the prevalent perspective that ADHD is a behavioural disorder and attend to the more subtle and/or internalised presentation that is common in females. It is essential to adopt a lifespan model of care to support the complex transitions experienced by females that occur in parallel to change in clinical presentation and social circumstances. Treatment with pharmacological and psychological interventions is expected to have a positive impact leading to increased productivity, decreased resource utilization and most importantly, improved long-term outcomes for girls and women.

The Effects of a Traditional Chinese Medication on Children with Attention-Deficit/Hyperactivity Disorder

Objective: This feasibility study examined the effects of a particular Traditional Chinese Medicine (TCM) herbal formula on attention-deficit/hyperactivity disorder (ADHD) and related problem behaviors. Design: A total of 79 participants aging 6-12 years consumed a granulated TCM herbal formula twice daily over a period of 3 months and underwent assessments at months 0, 3, and 6. Changes in ADHD symptoms and related behaviors were measured using the ADHD rating scale-IV (ADHD-RS-IV), child behavior checklist (CBCL), children's global sssessment scale (CGAS), as well as the clinical global impressions-severity (CGI-S) and improvement (CGI-I) scales. Results: Repeated measures mixed model analyses revealed significant differences in scores across time on all ADHD-RS-IV and CBCL subscales as well as on the CGAS, CGI-S, and CGI-I scales. Pairwise comparisons between months 0 and 3 as well as months 0 and 6 indicated significant improvements in scores. Scores also did not differ significantly between months 3 and 6. The results may suggest that this particular TCM formula possesses potential therapeutic qualities in the treatment of ADHD. Furthermore, changes in ADHD symptoms generally appear to be stable 3 months after discontinuation. However, these findings could also be attributed to placebo effects as well as reporting biases. Conclusion: This particular TCM formula may prove to be a useful adjunctive treatment for children with ADHD, and randomized controlled trials need to be conducted to evaluate its efficacy.

Long-term effects of theta/beta neurofeedback on EEG power spectra in children with attention deficit hyperactivity disorder

OBJECTIVE

Neurofeedback has been proposed as an effective alternative for pharmacological treatment in children with attention-deficit/hyperactivity disorder (ADHD), with potentially long-term and delayed benefits. However, the specificity of such long-term behavioral improvements remains inconclusive and therefore additional research into the neurophysiological effects of neurofeedback is needed. We compared long-term effects of theta/beta neurofeedback (NFB) to methylphenidate (MPH) and physical activity (PA, semi-active control intervention) on electroencephalogram (EEG) power spectra. Based on the vigilance stabilization model, we hypothesized further reductions in theta and alpha power in the NFB compared to the control groups.

METHOD

EEG power spectra (theta, alpha and beta) during resting and task conditions were recorded at pre-, post-intervention and 6-months follow-up in 67 children, aged 7-13 (NFB: n = 24, MPH: n = 23, or PA: n = 20).

RESULTS

Analyses revealed no power spectra differences at follow-up between MPH and NFB (range p = .165-.905) and PA and NFB (range p = .172-.822).

CONCLUSIONS

No evidence was found for the specificity of theta/beta NFB at follow-up.

SIGNIFICANCE

This was the first study into long-term neurophysiological effects of theta/beta NFB. Future studies are encouraged to explore both specific and non-specific mechanisms of NFB.

CLINICAL TRIALS REGISTRATION

Train Your Brain? Exercise and neurofeedback intervention for ADHD, https://clinicaltrials.gov/show/NCT01363544, Ref. No. NCT01363544.

The Effects of Extended-Release Stimulant Medication on Sleep in Children with ADHD

OBJECTIVE

Although stimulant medications, such as methylphenidate hydrochloride (MPH), are effective at reducing the core symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD), they may also disrupt children's sleep. This study aimed to investigate the acute impact of extended-release MPH on sleep using both actigraphy and polysomnography (PSG).

METHOD

Participants were 26 medication-naïve newly and rigorously diagnosed children with ADHD (23 males; 3 females) with a mean age of 8 years, 8 months (SD = 24.5mos) who were enrolled in a clinically-administered crossover medication trial with 2 conditions: 2 weeks of placebo and 2 weeks of MPH treatment. The effect of condition on sleep variables as measured by actigraphy (primary outcome) and PSG (secondary outcome) was analyzed using repeated measures MANOVAs.

RESULTS

Based on actigraphy data, total sleep time was significantly reduced by 30 minutes and sleep onset latency was significantly increased by 30 minutes in the MPH condition compared to the placebo condition (p<0.001). No differences were found in sleep efficiency. No statistically significant differences were found for the same variables assessed by PSG; however, the means were in the same direction as the actigraphy data. There was a significant increase in the relative percentage of stage N3 sleep by 3.2% during MPH treatment (p<0.05).

CONCLUSIONS

Increased sleep onset latency resulting in reduced total sleep time, which has been linked to poorer daytime functioning, is a potential adverse effect of stimulant medication which may require management to optimize outcome.

ADHD 24/7: Circadian clock genes, chronotherapy and sleep/wake cycle insufficiencies in ADHD

Objectives: The current paper addresses the evidence for circadian clock characteristics associated with attention-deficit hyperactivity disorder (ADHD), and possible therapeutic approaches based on chronomodulation through bright light (BL) therapy.Methods: We review the data reported in ADHD on genetic risk factors for phase-delayed circadian rhythms and on the role of photic input in circadian re-alignment.Results: Single nucleotide polymorphisms in circadian genes were recently associated with core ADHD symptoms, increased evening-orientation and frequent sleep problems. Additionally, alterations in exposure and response to photic input may underlie circadian problems in ADHD. BL therapy was shown to be effective for re-alignment of circadian physiology toward morningness, reducing sleep disturbances and bringing overall improvement in ADHD symptoms. The susceptibility of the circadian system to phase shift by timed BL exposure may have broad cost-effective potential implications for the treatment of ADHD.Conclusions: We conclude that further research of circadian function in ADHD should focus on detection of genetic markers (e.g., using human skin fibroblasts) and development of BL-based therapeutic interventions.

The Effectiveness of Mindfulness-Based Therapies for ADHD: A Meta-Analytic Review

Objective: Mindfulness-based therapies (MBTs) have been shown to be efficacious in treating internally focused psychological disorders (e.g., depression); however, it is still unclear whether MBTs provide improved functioning and symptom relief for individuals with externalizing disorders, including ADHD. To clarify the literature on the effectiveness of MBTs in treating ADHD and to guide future research, an effect-size analysis was conducted. Method: A systematic review of studies published in PsycINFO, PubMed, and Google Scholar was completed from the earliest available date until December 2014. Results: A total of 10 studies were included in the analysis of inattention and the overall effect size was d = -.66. A total of nine studies were included in the analysis of hyperactivity/impulsivity and the overall effect was calculated at d = -.53. Conclusion: Results of this study highlight the possible benefits of MBTs in reducing symptoms of ADHD.

Evaluation of Methylphenidate Safety and Maximum-Dose Titration Rationale in Attention-Deficit/Hyperactivity Disorder: A Meta-analysis

IMPORTANCE

Evidence on the titration of stimulant medications for attention-deficit/hyperactivity disorder (ADHD) is lacking. However, this lack of evidence has not prevented medication guidelines from specifying apparently arbitrary dose limitations, which could discourage clinicians from titrating methylphenidate to higher and, perhaps for some patients, more efficacious doses.

OBJECTIVE

To determine the evidence on dose titration and adverse events associated with dose titration of stimulants for ADHD.

DATA SOURCES

MEDLINE from 1946, Embase from 1974, and PsycINFO from 1806 through April 1, 2019, were searched to identify relevant articles.

STUDY SELECTION

The inclusion criteria were that (1) the study was conducted on children up to 18 years of age; (2) children had a diagnosis of ADHD according to the Diagnostic and Statistical Manual of Mental Disorders, or hyperkinetic disorder according to the International Classification of Diseases codes; and (3) the dose of methylphenidate was determined by titration.

DATA EXTRACTION AND SYNTHESIS

The PRISMA guidelines for abstracting data and assessing data quality and validity were followed. Quality assessment was undertaken using the Jadad scoring system. Statistical analysis was undertaken using a random-effects model.

MAIN OUTCOMES AND MEASURES

The outcomes of interest were (1) the doses used in published clinical trials, (2) the clinical justification given by researchers for their selected dose range, and (3) the adverse effects associated with methylphenidate when the dose is established by titration.

RESULTS

A total of 11 randomized clinical trials and 38 cohort studies were analyzed. The randomized clinical trials involved 1304 participants treated with methylphenidate and 887 controls; the 38 cohort studies included 5524 participants. Maximum doses of methylphenidate ranged from 0.8 to 1.8 mg/kg/d. Some studies detailed their method of titration, including starting dose, titration interval, increment dose, and maximum dose. Not all of these studies reported justification for the chosen dose range. Common adverse effects of methylphenidate included insomnia (odds ratio, 4.66; 95% CI, 1.99-10.92; P < .001), anorexia (5.11 higher than for those who took placebo; 95% CI, 1.99-13.14; P < .001), abdominal pain (1.9 times more likely; 95% CI, 0.77-4.77; P = .16), and headache (14% of participants; 95% CI, 10%-20%; P < .001).

CONCLUSIONS AND RELEVANCE

A range of maximum doses for methylphenidate was recommended in clinical studies; no discernable scientific justification for any particular dose was given. Reports of life-threatening adverse events were absent; further studies of the efficacy, tolerability, and safety of methylphenidate titrated purely on clinical grounds, without reference to any set maximum dose, are needed.

White noise as a possible therapeutic option for children with ADHD

Attention deficit/hyperactivity disorder (ADHD) is a condition that affects many children and adults throughout the world. ADHD symptoms have been associated with changes in catecholamine release. Current therapies for ADHD have a variety of limitations that invite additional therapeutic options. White noise therapy has previously been utilized to improve sleep and aspects of cognition in a variety of patient populations. Through a proposed phenomenon called stochastic resonance, white noise may have the ability to improve symptoms in children with ADHD. Empirically, white noise therapy has been able to improve certain tasks affected by ADHD symptoms, including speech recognition and reading and writing speed. Not all tasks affected by ADHD are improved, however, and significant logistical challenges remain before this therapy could be realistically implemented. In this review, there appears to be evidence that white noise therapy could be beneficial for patients with ADHD, and therefore further research is encouraged to establish parameters for maximum therapeutic benefit.

Cardiovascular Effects of Drugs Used to Treat Attention-Deficit/Hyperactivity Disorder: Part 1: Epidemiology, Pharmacology, and Impact on Hemodynamics and Ventricular Repolarization

Attention-deficit/hyperactivity disorder (ADHD) is a clinical syndrome characterized by persistent inattention, impulsivity, and hyperactivity. It is most commonly encountered in children and adolescents but may persist into adulthood. A variety of psychostimulant and nonpsychostimulant medications have proven to be successful in reducing inattention, impulsivity, and hyperactivity in those with ADHD. Psychostimulants used to treat ADHD include methylphenidate and related drugs and various amphetamine preparations. Non-psychostimulant medications used to treat ADHD include atomoxetine and two alpha-2 adrenergic agonists: guanfacine extended-release and clonidine extended-release. The psychostimulants and atomoxetine have been shown, on average, to increase heart rate by 3-10 beats/min, systolic blood pressure by 3-8 mm Hg, and diastolic blood pressure by 2-14 mm Hg. These drugs may also delay ventricular repolarization. The alpha-2 adrenergic agonists may reduce heart rate and blood pressure. For these reasons, there is concern about the safety of psychostimulant and nonpsychostimulant medications in patients with ADHD. In part 1 of this review, we discuss the epidemiology and natural history of ADHD, describe the pharmacology of drugs used to treat ADHD, and discuss in detail studies assessing the effects of ADHD drugs on blood pressure, heart or pulse rate, and electrocardiographic indices of ventricular repolarization.

Effect of physical exercises on attention, motor skill and physical fitness in children with attention deficit hyperactivity disorder: a systematic review

Children with attention deficit hyperactivity disorder (ADHD) are educated in classrooms along with typically developing children. Those with ADHD, however, find it difficult to participate in routine educational and recreational activities as they encounter problems associated with behaviour, attention, motor skills and physical endurance. Traditionally, the management of children with ADHD has focussed primarily on problems with cognition and has been heavily dependent on pharmaceutical interventions and, to a lesser extent, on non-pharmaceutical measures. More recently, experts have increasingly advocated the use of exercises in alleviating symptoms associated with ADHD. The primary objective of this review was to summarize research that examined the role of exercises on deficits related to attention, motor skills and fitness in children with ADHD. A search of the available literature was conducted using a combination of relevant key words in the following databases: PubMed, MEDLINE, Google Scholar, Embase and Cochrane review. The search filtered 3016 studies of potential relevance, of which 2087 were excluded after screening titles and abstracts as per the inclusion criteria. Thirty-four (34) studies were analysed in greater depth, and 16 were excluded after detailed consideration as they did not match the inclusion (PEDro score > 4) and exclusion criteria. Three (3) additional studies were excluded as they lacked exercise prescription details such as intensity, duration and frequency of exercise. Finally, 15 studies were analysed with a focus on the effects of physical exercises on attention, hyperactive behaviour, motor skills and physical fitness in ADHD children. Overall, the studies reviewed were of moderate-to-high quality and reported benefits of a variety of exercise programmes in improving motor skills, physical fitness, attention and social behaviour in children with ADHD. However, there was limited information regarding school-based programmes, the effects of structured exercise programmes independently or in combination with cognitive-based therapies, and the long-term benefits of exercises in alleviating behavioural problems in these children.

Methylphenidate and atomoxetine prescribing trends in children in the Western Cape Province of South Africa, 2005-2013

Background

There is paucity of data on methylphenidate and atomoxetine prescribing patterns in South African children.

Aim

To describe the prescribing trends of these agents in children residing in the Western Cape Province.

Setting

South African private health sector.

Methods

Longitudinal drug utilisation study on medicine claims data from 2005–2013, focussing on the number of patients and prescriptions per patient.

Results

The total number of patients increased by 29.5% from 2005 to 2013. The majority were boys (male:female ratio, 3.5:1), and between the ages of > 6 and ≤12 years in 2005 and >12 and ≤18 years in 2013. More than 75% of patients received methylphenidate or atomoxetine in the City of Cape Town Metropolitan municipality. Prescriptions for methylphenidate and atomoxetine increased by 45.5% overall from 2005 to 2013 (p < 0.001), with that for methylphenidate and atomoxetine increasing by 36.0% and 314.5%, respectively. The average number of annual methylphenidate prescriptions per patient increased from 3.96 ± 2.92 (95% CI, 3.69–4.23) in 2005 to 4.38 ± 2.85 (95% CI, 4.14–4.61) in 2013 (Cohen’s d = 0.14) and for atomoxetine from 2.58 ± 1.86 (95% CI, 1.80–3.37) in 2005 to 4.85 ± 3.66 (95% CI, 3.84–5.86) in 2013 (Cohen’s d = 0.62).

Conclusion

Although the total number of patients and prescribing of methylphenidate and atomoxetine increased significantly from 2005 to 2013, a slight downward trend was observed in the mean number of prescriptions per patient per year from 2008 onwards. These prescribing patterns warrant further research.

A 6-month follow-up of an RCT on behavioral and neurocognitive effects of neurofeedback in children with ADHD

To assess the long-term effects of neurofeedback (NFB) in children with attention deficit hyperactivity disorder (ADHD), we compared behavioral and neurocognitive outcomes at a 6-month naturalistic follow-up of a randomized controlled trial on NFB, methylphenidate (MPH), and physical activity (PA). Ninety-two children with a DSM-IV-TR ADHD diagnosis, aged 7-13, receiving NFB (n = 33), MPH (n = 28), or PA (n = 31), were re-assessed 6-months after the interventions. NFB comprised theta/beta training on the vertex (cortical zero). PA comprised moderate to vigorous intensity exercises. Outcome measures included parent and teacher behavioral reports, and neurocognitive measures (auditory oddball, stop-signal, and visual spatial working memory tasks). At follow-up, longitudinal hierarchical multilevel model analyses revealed no significant group differences for parent reports and neurocognitive measures (p = .058-.997), except for improved inhibition in MPH compared to NFB (p = .040) and faster response speed in NFB compared to PA (p = .012) during the stop-signal task. These effects, however, disappeared after controlling for medication use at follow-up. Interestingly, teacher reports showed less inattention and hyperactivity/impulsivity at follow-up for NFB than PA (p = .004-.010), even after controlling for medication use (p = .013-.036). Our findings indicate that the superior results previously found for parent reports and neurocognitive outcome measures obtained with MPH compared to NFB and PA post intervention became smaller or non-significant at follow-up. Teacher reports suggested superior effects of NFB over PA; however, some children had different teachers at follow-up. Therefore, this finding should be interpreted with caution. Clinical trial registration Train your brain and exercise your heart? Advancing the treatment for Attention Deficit Hyperactivity Disorder (ADHD), Ref. no. NCT01363544, https://clinicaltrials.gov/show/NCT01363544 .

Systematic review of meditation-based interventions for children with ADHD

Meditation-based interventions such as mindfulness and yoga are commonly practiced in the general community to improve mental and physical health. Parents, teachers and healthcare providers are also increasingly using such interventions with children. This review examines the use of meditation-based interventions in the treatment of children with Attention-Deficit Hyperactivity Disorder (ADHD). Electronic databases searched included PsycINFO, Medline, CINAHL, and AMED. Inclusion criteria involved children (aged to 18 years) diagnosed with ADHD, delivery of a meditation-based intervention to children and/or parents, and publication in a peer-reviewed journal. Studies were identified and coded using standard criteria, risk of bias was assessed using Risk of Bias in Non-randomised Studies- of interventions (ROBINS-I), and effect sizes were calculated. A total of 16 studies were identified (8 that included children in treatment, and 8 that included combined parent-child treatment). Results indicated that risk of bias was high across studies. At this stage, no definitive conclusions can be offered regarding the utility of meditation-based interventions for children with ADHD and/or their parents, since the methodological quality of the studies reviewed is low. Future well designed research is needed to establish the efficacy of meditation-based interventions, including commonly used practices such as mindfulness, before recommendations can be made for children with ADHD and their families.

Medication prescribed by Australian paediatricians: Psychotropics predominate

AIM

The aims of this study were to examine: (i) medications prescribed by Australian general and community paediatricians, (ii) predictors of prescribing (child age, gender) and (iii) changes in medication prescription between 2008 and 2013.

METHODS

Two patient-level practice national audits were conducted by the Australian Paediatric Research Network in 2008 and 2013. General and community paediatricians in outpatient clinics and private practices recorded demographic data, diagnoses and medications prescribed for all patients seen over a 2-week period.

RESULTS

In 2008, 199 paediatricians submitted data on 8345 consultations, and in 2013, 180 paediatricians submitted data on 7102 consultations. The most frequently prescribed drug class was psychotropics, prescribed for 46.8% of patients with developmental-behavioural/mental health (DB/MH) diagnoses in 2008 and 49.8% in 2013 (P = 0.015). Within this class, in 2013, the stimulants were prescribed in 35.3% of DB/MH consultations, antidepressants in 7.8% and antipsychotics in 5.6%. The next most frequently prescribed drug classes were laxatives (4.6% of all consultations in 2013), asthma preventers (4.1%), melatonin (3.7%), asthma relievers (2.6%) and proton-pump inhibitors (2.2%), topical corticosteroids (1.8%) and antihistamines (1.4%). Medication prescription was predicted by patient age (P < 0.001, both audits) and male gender (P < 0.01, both audits) but not by measured prescriber variables. The rates of prescribing of psychotropics, melatonin, laxatives and enuresis medications increased between 2008 and 2013.

CONCLUSIONS

Australian paediatricians prescribe mostly psychotropic medications, and the amount prescribed appears to be increasing. Paediatricians need good training and professional development in mental health diagnosis and management and the rational prescribing of psychotropic medications.

Has Psychiatric Medication Reduced Crime and Delinquency?

Several strands of research are consistent with the possibility that expansions in psychiatric medication usage have reduced crime and delinquency. Estimates suggest that medication usage has increased to as much as 9% of the youth population and up to 20% of the adult population in the United States and is high among populations associated with the criminal justice system. Studies show that four classes of commonly used psychiatric medication do reduce aggressive behavior, and crime rates are lower among diagnosed patients receiving such medications compared to those not. Prescriptions for medication increased fivefold for youth during the time that crime has declined in the United States and elsewhere, and two population-level analyses find some association between prescription rates and crime trends over time. However, true experimental studies are lacking, and one of the better trend studies does not show strong associations. This article proposes a research agenda for this issue.

Psychiatric diagnoses and medication treatment among patients presenting for paediatric weight management: associations with adiposity, aerobic fitness and cardiometabolic health

We compared anthropometry, cardiometabolic risk and aerobic fitness among obese youth in weight management who were diagnosed with one or more psychiatric disorders (PD), with (PD+M) or without (PD-M) a prescribed psychotropic medication with those with no PD (NPD). Physical measures were evaluated at baseline, and psychiatric diagnoses and related medications were identified from medical records. Of 99 patients 64 (65%) had a diagnosed PD, and of those, 23 (36%) had a related medication (PD+M). Compared to NPD, PD-M had a higher body mass index (BMI) (P = 0.003), BMI z-score (P = 0.015), percent body fat (P = 0.005) and waist circumference (P < 0.001), after adjusting for age, but PD+M did not. Cardiometabolic risk did not differ between groups, but aerobic fitness was lower among PD-M (P = 0.001) and PD+M (P = 0.008) compared to NPD. Obese youth in weight management exhibit high rates of psychiatric diagnoses that are associated with lower fitness and higher adiposity and may impact treatment efficacy.