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Adaptive changes related to medication treatment of ADHD: listening to parents of children in clinical trials of a novel nonstimulant medication.

The DSM-IV diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD) have proved useful in providing a common language for diagnosing, treating, and researching the disorder. Despite the utility of current ADHD diagnostic criteria, sophisticated theoretical conceptualizations of the etiology of ADHD have described a much more complex disorder that includes a range of neuropsychological impairments (such as working memory deficits and other executive dysfunction) and underlying structural and functional neuropathology (e.g., caudate nucleus volume, frontal lobe activity). Inattention, hyperactivity, and impulsivity, the hallmark triumvirate symptoms of ADHD, may be better viewed as some of the many meaningful symptoms with roots in executive-functioning impairment. Outcomes of brain-imaging studies, public skepticism about diagnosis and treatment, and a demand for meaningful clinical outcomes of treatment point to a considerable need to broaden treatment-outcome criteria beyond the DSM-IV domains. The wide-ranging decrements in adaptive function and quality of life reported by parents of children diagnosed with ADHD further support core executive dysfunction. Emerging findings concerning medication-related improvements in adaptive functioning (e.g., social, emotional, academic), as well as the rapid search for the neuropathology that may underlie these improvements, are fueling interest in the assessment of adaptive function in clinical trials. In a series of ongoing clinical trials of a novel nonstimulant medication for ADHD, many parents reported significant improvements in the lives of their children beyond the DSM-IV criteria. These parental reports, despite their inherent sources of error, underscore the importance of including broader and more meaningful clinical outcome assessment in clinical trials. Research protocols that omit parental interviews that assess adaptive and executive function may well overlook several meaningful and consequential medication-related improvements.

Adolescent↗

[Exploratory eye movement in children with ADHD].

OBJECTIVE: To explore the character of the exploratory eye movement in ADHD children. METHODS: The eye mark recorder (model IV) was used to record the eye movements in 33 ADHD children and 33 normal controls matched by age and sex, using t-test to compare the differences of the numbers of eye fixations, total eye scanning lengths, mean eye scanning lengths, cognitive search scores, responsive search scores and D values between the two groups. RESULTS: ADHD children showed significantly fewer frequent numbers of eye fixations and longer mean eye scanning lengths than the normal controls. The responsive search score of ADHD children was significantly lower than that of the control group. ADHD children had a positive D value and the normal controls had a negative D value. CONCLUSION: ADHD children had fewer frequent numbers of eye fixation, longer mean eye scanning length and lower responsive search score than the normal controls, which may be the evidence of executive dysfunctions.

Adolescent↗

Detection of malingering in assessment of adult ADHD.

Comparisons of two assessment measures for ADHD: the ADHD Behavior Checklist and the Integrated Visual and Auditory Continuous Performance Test (IVA CPT) were examined using undergraduates (n=44) randomly assigned to a control or a simulated malingerer condition and undergraduates with a valid diagnosis of ADHD (n=16). It was predicted that malingerers would successfully fake ADHD on the rating scale but not on the CPT for which they would overcompensate, scoring lower than all other groups. Analyses indicated that the ADHD Behavior Rating Scale was successfully faked for childhood and current symptoms. IVA CPT could not be faked on 81% of its scales. The CPT's impairment index results revealed: sensitivity 94%, specificity 91%, PPP 88%, NPP 95%. Results provide support for the inclusion of a CPT in assessment of adult ADHD.

Adult↗

Inhibitory capacity in adults with symptoms of Attention Deficit/Hyperactivity Disorder (ADHD).

Adult participants for the current study were placed into one of two groups depending on whether they manifested either high or low symptom levels of Attention Deficit/Hyperactivity Disorder (ADHD) as determined by the Wender Utah Rating Scale. Participants were also assessed on a battery of cognitive tasks as well as symptoms of depression, anxiety and substance abuse. The ADHD symptom groups were comparable in age and symptoms of depression, anxiety, and substance abuse. Adults with greater ADHD symptomatology performed more poorly on cognitive measures of response inhibition (the Stop-Signal task) and visual attention, compared to those with fewer ADHD symptoms. Regression analysis indicated the Stop-Signal task accounted for a greater proportion of the variance of ADHD symptomatology than any other cognitive variable. The conclusions from the findings are discussed in relation to self-regulation model of ADHD.

Adult↗

ADHD treatment across the life cycle.

Since attention-deficit/hyperactivity disorder (ADHD) is usually diagnosed in children, evidence from the studies of pharmacologic treatments for children with ADHD is used to inform pharmacologic treatment recommendations for adults. A large percentage of children diagnosed with ADHD have symptoms that persist into adolescence and adulthood. Evidence shows that pharmacologic treatments improve functional outcomes in children with ADHD, and studies using similar pharmacologic treatments show positive results in adults with ADHD. This article reviews the use of long-acting methylphenidate, mixed amphetamine salts, desipramine, monoamine oxidase inhibitors, bupropion, and atomoxetine in studies of children, adolescents, and adults with ADHD.

Adolescent↗

When the child with ADHD grows up.

BACKGROUND: There is significant controversy surrounding attention deficit hyperactivity disorder (ADHD). While the existence of this disorder is generally accepted, debate continues in relation to aspects of assessment, as well as the effectiveness and choice of treatment options and their continuation into adult life. Management is further complicated as people with ADHD often have chaotic lives which impedes medication compliance and motivation to continue treatment vacillates. Concern also exists over the misuse of amphetamine-like medications by some patients. OBJECTIVE: This case study does not provide comprehensive information on current diagnosis and ADHD treatment guidelines, but explores the issues and management role of general practitioners treating patients with ADHD. DISCUSSION: The diagnosis of ADHD is common, and many patients are managed using a range of social and behavioural interventions that are commonly combined with pharmacotherapies (provided in the main by psychiatrists and paediatricians). However, while specialists may appropriately choose not to treat where a diagnosis is unclear, or discontinue treatment for reasons such as doubtful response to treatment, possible medication misuse, concurrent illicit drug use or poor motivation, GPs frequently continue to manage ongoing care and the impact of ADHD on the rest of the family. When the specialist formulation suggests there is little to gain from further treatment, the GP is likely to be the sole health professional remaining engaged in support and ongoing management.

Adolescent↗

Multicenter, randomized, open-label study of OROS methylphenidate versus atomoxetine: treatment outcomes in African-American children with ADHD.

The Formal Observation of Concerta versUs Strattera (FOCUS) study was conducted to assess, in children with ADHD, treatment outcomes with Concerta [OROS methylphenidate (MPH)], a once-daily controlled-release medication, and Strattera, (atomoxetine), a selective noradrenaline reuptake inhibitor, Because of the lack of data in minority groups treated for ADHD, the present subgroup analysis was conducted to determine the effectiveness and tolerability of ADHD treatments in African-American patients who were randomized to OROS MPH (n=125) or atomoxetine (n=58) during the FOCUS study. At the end of the study, the mean dose of OROS MPH was 32.8 +/- 10.9 mg and that of atomoxetine was 1.1 +/- 0.4 mg/kg. The results demonstrated that both treatments were associated with significant improvements in ADHD symptoms from baseline; however, patients who received OROS MPH demonstrated significantly greater improvements in total ADHD symptoms, inattentiveness and global improvement. The incidence of adverse events was similar in both treatment groups. OROS MPH and atomoxetine are effective and tolerable in the treatment of African Americans with ADHD, and significantly greater treatment responses were observed in patients receiving OROS MPH compared with those receiving atomoxetine over three weeks. Additional studies are needed to evaluate treatment response in this population.

Atomoxetine Hydrochloride↗

[Genetic background of ADHD: genes of the serotonergic system, other candidate genes, endophenotype].

Recent studies have shown that in the aetiology of attention-deficit hyperactivity disorder (ADHD) genetic factors may be of importance. Biochemical and pharmacological studies reveal a connection between abnormalities of dopaminergic, adrenergic and serotonergic system and ADHD. Therefore genes for enzymes synthesizing or degrading proper neurotransmitters, genes for adequate transporters and receptors and genes for other substances, which altered the level of neurotransmitters, are studied. Many authors describe the connection between ADHD development and the synaptosomal-associated protein 25 (SNAP-25) gene. This protein plays a role in catecholamine secretion. Its higher expression is specific for neurones. SNAP-25 gene mutation may change this protein level, function of synapse and neurotransmitters storage. Acetylcholine receptor alpha4 subunit gene stimulation increases the dopamine level. Therefore this receptor gene may be important in the aetiology of ADHD studies. Other possible factors in ADHD background are substance influence on brain maturation, including N-methyl-D aspartate glutamate receptor 2A gene polymorphism (GRIN2A) and brain derived neurotrophic factor (BDNF) gene. One of the greatest challenges in studying the genetic basis of psychiatric disorders is to find appropriate ways to define the relevant endophenotype. ADHD often coexists with other psychiatric disorders, including specific developmental disorders, conduct disorders, obsessive-compulsive disorder and early onset of bipolar disorder.

Attention Deficit Disorder with Hyperactivity↗

An open-label, prospective study of guanfacine in children with ADHD and tic disorders.

OBJECTIVES: To evaluate the efficacy and safety of guanfacine in children with attention-deficit hyperactivity disorder (ADHD) and tic disorders. MATERIAL AND METHOD: Twenty-five medication-free subjects (23 males and 2 females), aged 7-16 (mean = 10.6 +/- 2.0) years participated in an 8-week open-label guanfacine study. Subjects were recruited from a specialty clinic for children with tic disorders over a four-year period. Eligibility criteria included presence of ADHD (any type), a tic disorder (any type), and being medication free for two weeks. Outcome measures included the Hyperactivity Index of the Conners Parent Questionnaire, the teacher-rated ADHD Rating Scale, and the Yale Global Tic Severity Scale (YGTSS). RESULTS: All subjects met criteria for ADHD (combined type N = 22; predominantly inattentive type N = 3) and a tic disorder (Tourette's Disorder N = 20; chronic motor tic disorder N = 5). At an average dose of 2.0 +/- 0.6 mg/ day, guanfacine was associated with mean improvement of 27% on the Hyperactivity Index (N = 25; t = 4.61; p < 0.001), 32% on the total score of the teacher-rated ADHD Scale (N = 19; t = 5.27; p < 0.001), and 39% on the total tic severity scale (N = 19; t = 4.17; p < 0.001). Mild and statistically insignificant decreases in blood pressure and pulse were observed in the sample as a whole. Five subjects had endpoint systolic blood pressure below 1 SD from their age and gender norms. CONCLUSION: Results of this open-label study add to the growing data base on the safety and efficacy of guanfacine in children with ADHD and tic disorders.

Adolescent↗

[Neuropsychological performance in ADHD and tic-disorders: a prospective 1-year follow-up].

Inhibitory deficits in the brain play a major role in the pathophysiology of ADHD and tic disorders. Impairment of executive functions (EF) may be directly linked to these abnormalities. Hence, parallel to an amelioration of symptomatology in ADHD and in tic disorders a decline of EF impairment should be observed. This phenomenon would indirectly suggest that there exist inhibitory deficits in these disorders. Age and IQ matched samples of boys one with ADHD (n = 15; age: M = 128 months SD = 16, IQ: M = 101 SD = 11), the other with tic disorders (n = 14; age: M = 132 months SD = 16; IQ: M = 101 SD = 10) have been compared with a group of controls (n = 23; age: M = 131 months SD = 13; IQ: M = 108 SD = 7). Reexamination has been performed after about one year. In ADHD EF deficits found at the beginning were decreased at the second testing after about one year when symptomatology had ameliorated. The boys with tic disorders revealed no differences compared to controls and no changes over time. The reduction of EF deficits with time in boys with ADHD is best explained by neuronal maturational processes, which are very intensive in the children with ADHD of this age.

Attention↗

The diagnosis and medical treatment of ADHD in children and adolescents in primary care: a practical guide.

Attention deficit hyperactivity disorder (ADHD) is one of the most common psychiatric disorders of childhood with approximately 3%-5% of children affected. ADHD is characterized by inattention, impulsivity, and hyperactivity. Many children will present to the primary care provider with concerns regarding ADHD behaviors. The approach to ADHD evaluation includes the history, physical exam, and use of ADHD rating scales. The use of medication to treat ADHD is an important part of management.

Adolescent↗

[ADHD, a 'fashion' that won't go out of fashion. An illustration of the many-sidedness of earlier psychiatry].

BACKGROUND: This article reviews the older Dutch literature on what is now known as ADHD (attention deficit hyperactivity disorder). METHOD: Because this older literature is not included in electronic databases, it was traced, in a systematic and a selective manner, by means of bibliographic references. RESULTS: It is often assumed that ADHD is a purely Anglo-Saxon phenomenon that was introduced into The Netherlands along with the concept of MBD (minimal brain damage). This assumption is incorrect. In fact, ADHD has had quite a long, respectable history of its own in The Netherlands (and in surrounding countries). The antecedents of ADHD were regarded as very common phenomena. Over the years these concepts have often been the subject of considerable controversy. Biological factors were thought to be important in the etiology. CONCLUSION: It would be wrong to regard ADHD only as a fashionable ailment originating in the age of computers and working mothers. Equally untenable is the current view that pre-DSM III child psychiatrists attributed psychiatric disorders solely to parental influences ('parent-blaming'). The same conclusion was drawn in other publications by the author. The history of ADHD thus demonstrates that, contrary to general belief, early psychiatry in The Netherlands was more balanced and many-sided.

Adolescent↗

The effects of magnesium physiological supplementation on hyperactivity in children with attention deficit hyperactivity disorder (ADHD). Positive response to magnesium oral loading test.

Children with ADHD are 'a group at risk' as far as their further emotional and social development and educational possibilities are concerned, and the consequences of the lack of an appropriate therapy appears to be serious. Some of these children do not respond to prevailing therapy methods. It is reported that dietetic factors can play a significant role in the etiology of ADHD syndrome, and magnesium deficiency can help in revealing hyperactivity in children. The aim of our work was to assess the influence of magnesium supplementation on hyperactivity in patients with ADHD. The examination comprised 50 hyperactive children, aged 7-12 years, who fulfilled DSM IV criteria for ADHD syndrome, with recognized deficiency of magnesium in the blood (blood serum and red blood cells) and in hair using atomic absorption spectroscopy. In the period of 6 months those examined regularly took magnesium preparations in a dose of about 200 mg/day. 30 of those examined with ADHD showed coexisting disorders specific to developmental age, and 20 of them showed disruptive behaviour. The control group consisted of 25 children with ADHD and magnesium deficiency, who were treated in a standard way, without magnesium preparations. 15 members of this group showed coexisting disorders specific for developmental age, and 10 members showed disruptive behaviour. Hyperactivity was assessed with the aid of psychometric scales: the Conners Rating Scale for Parents and Teachers, Wender's Scale of Behavior and the Quotient of Development to Freedom from Distractibility. In the group of children given 6 months of magnesium supplementation, independently of other mental disorders coexisting with hyperactivity, an increase in magnesium contents in hair and a significant decrease of hyperactivity of those examined has been achieved, compared to their clinical state before supplementation and compared to the control group which had not been treated with magnesium.

Administration, Oral↗

Familial subtypes of attention deficit hyperactivity disorder: a 4-year follow-up study of children from antisocial-ADHD families.

ADHD is a familial disorder with high rates of comorbidity with conduct disorder in childhood and antisocial personality and substance use disorders in adulthood. A growing literature suggests that ADHD with antisocial comorbidity may be nosologically distinct from other forms of ADHD. Previously, we proposed a family-based stratification that defined Antisocial families as those with either conduct disorder or antisocial personality disorder in the probands or relatives. To provide predictive validity for that stratification, we assessed psychopathology in these families 4 years after their initial assessment. Results show that the probands and siblings from Antisocial families had higher rates of psychopathology during the 4-year follow-up period compared with siblings from Non-antisocial and control families. They also had more deviant ratings on the Child Behavior Checklist (especially for anxious/depressed, delinquent, and aggressive behavior). We found fewer group differences in the academic, psychosocial, and intellectual correlates of ADHD. These results confirm and extend previous work indicating that Antisocial ADHD may be a nosologically and clinically meaningful subform of ADHD.

Adolescent↗

Failure to replicate an excess of the long dopamine D4 exon III repeat polymorphism in ADHD in a family-based study.

The DRD4 exon III repeat polymorphism has been associated in adults with Novelty Seeking personality traits and in children with attention deficit hyperactivity disorder (ADHD) in some but not all studies. In a previous report we failed to observe preferential transmission of the long DRD4 repeat in ADHD compared to the haplotype relative risk (HRR) derived control group in a group of 49 triads (both parents and ADHD child) recruited in the Jerusalem area. In the current study we independently recruited an additional group of 49 triads from a different geographical location (Petak Tikvah) in Israel but having a similar ethnic background. In contrast to previous findings from a number of groups, in the current study an excess of the long DRD4 alleles was observed in the HRR control group compared to the ADHD subjects (Likelihood ratio = 5.50, P = 0. 02). In the expanded Israeli group of 98 triads so-far examined for the DRD4 repeat polymorphism there is an excess of the long alleles in the HRR control group (Likelihood ratio = 3.81, P = 0.05). These results attest to the complexity of ADHD inheritance and the likelihood that genetic heterogeneity characterizes this disorder especially across ethnic and cultural boundaries.

Adolescent↗

Role of genetic factors in depression based on studies of Tourette syndrome and ADHD probands and their relatives.

Tourette syndrome (TS) is a common, neuropsychiatric disorder which has many similarities to attention deficit hyperactivity disorder (ADHD). TS probands have a high frequency of a variety of behavioral disorders including depression. The depression may be due to a pleiotrophic effect of the Gts genes, proband ascertainment bias, or a result of coping with the chronic tics. To distinguish between these hypotheses we examined the responses to 17 Diagnostic Interview Schedule questions to evaluate the 9 DSM-III-R criteria for major depressive episode in 1,080 adults consisting of TS and ADHD probands, their relatives and controls. Using a Bonferonni corrected p there was a significant progressive increase in 16 of 17 depressive symptoms and for a life time history of a major depressive episode in groups with increased genetic loading for Gts genes. Similar trends were seen in the small number of ADHD probands and their relatives. There was also a significant increase for these variables in non-proband TS relatives versus non-TS relatives, indicating the association of depression with Gts genes was not due to ascertainment bias or the inappropriate choice of controls. Multiple linear regression analysis indicated that obsessive-compulsive behaviors, sex, ADHD, drug abuse, and age all showed a more significant effect on depressive symptoms than the number of tics. The presence or absence of TS in the relatives had a much greater effect on risk for depression than the presence or absence of an episode of major depression in the proband. These results are consistent with the hypothesis that Gts and ADHD genes play a major role in depression.

Adolescent↗

No association of the dopamine transporter gene 3' VNTR polymorphism with ADHD subtypes in a population sample of twins.

Dopamine pathway genes have been the subject of a variety of studies testing the association of candidate genes and liability for attention-deficit hyperactivity disorder (ADHD). Due to the known effects of stimulant medications such as methylphenidate on the dopamine transporter, a variety of case control and family-based transmission distortion genetic studies of ADHD have focused on DAT1 polymorphisms. The most widely reported positive finding has been with a variable number of tandem repeats (VNTR) polymorphism of unknown function in the 3' untranslated region of the DAT1 gene. In this report, we test for association of alleles of this polymorphism with ADHD using population-derived samples of twins. We use the transmission disequilibrium test and ADHD subtypes defined by both DSM-IV and latent class criteria. We fail to demonstrate any significant association or trend for association of any of the VNTR alleles with any of the variously defined ADHD subtypes.

Adolescent↗

Etiology of the comorbidity between RD and ADHD: exploration of the non-random mating hypothesis.

The present research sought to test the validity of the non-random mating hypothesis in a community sample in order to determine whether it contributes significantly to the comorbidity between attention-deficit/hyperactivity disorder (ADHD) and reading disability (RD) and to test whether the two disorders segregate independently. Data were gathered from 394 twin participants of the Colorado Learning Disabilities Research Center (CLDRC) and their biological parents. Parents were asked to complete retrospective questionnaires regarding their own ADHD and RD symptomatology as children, as well as rate their children on DSM-IV ADHD symptomatology before age 12. Twin RD was assessed by a composite score consisting of several reading measures. Chi-square and correlational analyses assessed the presence of non-random mating, as well as whether the two disorders were transmitted independently. Non-random mating between those with ADHD and those with RD did not significantly contribute to the comorbidity of the two disorders. Furthermore, there was some evidence that these two disorders did not segregate independently in this sample. These results are consistent with recent evidence that ADHD and RD are often comorbid because of significant genetic overlap. There was little evidence to support that non-random mating also contributes to this comorbidity in the present sample.

Adolescent↗