Abstract
This study compares the efficacy and tolerability of central nervous system (CNS) stimulants in children with attention deficit hyperactivity disorder (ADHD) with and without prominent irritability (IRR) over the course of 30 months. This is a secondary analysis of a study examining growth patterns in medication naïve children with ADHD subsequently treated with CNS stimulants (predominantly OROS-Methylphenidate, up to 54 mg per day) for 30 months. Participants had to meet full diagnostic criteria for ADHD and been treated with CNS stimulants for under 30 days. Children were classified as IRR if they were rated as pretty much or very much on either of the “often angry” or easily annoyed” items plus “lose temper,” items of the Disruptive Behavior Disorders Rating Scale (DBDRS). Structured ratings of ADHD symptoms, impairment, side effects, and symptoms of oppositional defiant disorder (ODD) were collected every 2–12 weeks for the duration of the study. Medication use was measured by pill count and parent report. The IRR group comprised 28% of all participants. The IRR group had significantly higher levels of ADHD and ODD symptoms, impairment, and side effects ratings at baseline. In the IRR group, ODD symptoms, emotional lability, and impairment significantly decreased for participants with higher medication use. Total side effects increased for non-IRR participants with higher medication use. Emotional side effects decreased for IRR participants with higher medication use. Central nervous system stimulants were a tolerable and efficacious treatment in treatment naïve youth with ADHD with irritability.Clinical Trials Registration: NCT01109849
Highlights
Persistent non-episodic irritability is one of the most common presentations in child mental health [1] and presents in youth with a wide range of psychiatric diagnoses [2]
As part of a NIH-funded longitudinal study examining the impact of ER central nervous system (CNS) stimulants on physical growth in medication naïve children with attention deficit hyperactivity disorder (ADHD) [29], we systematically examined the efficacy and tolerability of CNS stimulants in 230 children with ADHD with and without prominent irritability over the course of 30 months
It was hypothesized that: (a) prior to any use of CNS stimulants, children with high levels of irritability would have higher levels of ADHD symptoms, other behavior problems, physical and emotional symptoms often classified as side effects of CNS stimulants and impairment than children with low levels of irritability; (b) medication would be associated with sustained reductions in ADHD symptoms, and impairment, and (c) irritability would not moderate changes in symptoms, emotional lability, or other side effect levels with CNS stimulants
Summary
Persistent non-episodic irritability is one of the most common presentations in child mental health [1] and presents in youth with a wide range of psychiatric diagnoses [2]. The MTA analysis assessed only the impact of irritability on the efficacy of CNS stimulants for reducing ADHD symptoms scores and irritability, using the same measure to both define irritability and measure treatment effects. It did not assess the impact of irritability on treatment tolerability or the change in impairment. Outside of the MTA, most studies assessing the impact of CNS stimulants on irritability only briefly examined treatment effects before adjunctive medications were added They enrolled participants meeting criteria for disruptive mood dysregulation disorder (DMDD)/severe mood dysregulation or recurrent physical aggression [8, 17,18,19,20,21,22]. It was hypothesized that: (a) prior to any use of CNS stimulants, children with high levels of irritability would have higher levels of ADHD symptoms, other behavior problems, physical and emotional symptoms often classified as side effects of CNS stimulants and impairment than children with low levels of irritability; (b) medication would be associated with sustained reductions in ADHD symptoms, and impairment, and (c) irritability would not moderate changes in symptoms, emotional lability, or other side effect levels with CNS stimulants
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