We still need to know more about adolescents with attention deficit hyperactivity disorder who undergo surgery for severe obesity

Abstract

Metabolic and bariatric surgery (MBS) is increasingly used to treat adolescents with severe obesity. A growing number of studies, including the Swedish Adolescent Morbid Obesity Surgery (AMOS) study, show that MBS is indeed safe and effective in adolescents.1 However, it has also has been shown that adolescents undergoing surgery for obesity are more vulnerable to mental health problems than the middle-aged adults who are normally included in MBS studies. AMOS has demonstrated that adolescents reported higher rates of low mood and clinical depression than previously found in adults.2 In 2018, the American Society for Metabolic and Bariatric Surgery issued guidelines that state that MBS is a proven, effective treatment for severe obesity in adolescents and should be considered the standard of care.3 The guidelines also state that most mental health problems should not be considered contraindications, other than active substance use disorder, active psychosis and current suicidality. The guidelines recommend that adolescents with mental health disorders who present for MBS should be monitored and offered postoperative care to promote a positive outcome.3 While some specific psychiatric disorders are discussed in the Society's guidelines, attention deficit hyperactivity disorder (ADHD) is not addressed. In this issue of Acta Paediatrica, Leib et al demonstrated a high incidence (28.6%) of ADHD in a sample of 84 adolescents seeking MBS.4 One of the major strengths of this paper is its rigorous assessment of ADHD, resulting in reliable prevalence figures. Having an ADHD diagnosis was not related to outcome in terms of weight loss during the first year after MBS. However, a significant association was found between reporting more ADHD symptoms at baseline, regardless of a formal diagnosis, and more weight loss during the first year. The association between ADHD and obesity is not fully understood, especially in children and adolescents. Two meta-analyses published in 2016 both showed an increased risk of obesity in adult individuals with ADHD,5, 6 but reached different conclusions for children and adolescents. Nigg et al found no clinically relevant association between ADHD and excess weight in children and adolescent boys and only a possible clinically relevant association between excess weight and ADHD in adolescent girls with comorbid disorders.5 In contrast, Cortese et al found that the pooled prevalence of obesity was 40% higher in children with ADHD than in those without ADHD.6 Before the study by Leib et al, few studies had reported the prevalence of ADHD in adolescents seeking MBS. One American study reported that when a clinical interview was used to assess 200 adolescents presenting for MBS, 6% were diagnosed with ADHD.7 Even if the actual prevalence was substantially lower than reported in the Lieb et al study, ADHD tied with major depressive disorder as the most commonly diagnosed disorder in the sample (5.5%).7 Even less is known about how ADHD in adolescents affects outcomes after MBS. Leib et al found no association between ADHD and weight loss, and this is in agreement with previous findings in adults.4 A 2019 meta-analysis of outcomes in adults after bariatric surgery also showed no significant difference in weight loss between patients with and without ADHD.8 Leib et al's findings that those diagnosed with ADHD lost as much weight as controls, and those reporting ADHD symptoms lost more than controls, might not seem surprising. The physical mechanisms of MBS are very powerful during the first year. This means that the behavioural problems associated with ADHD and its symptoms, such as difficulties with impulse regulation and planning, might be ameliorated by surgery-induced regulatory mechanisms. It is obvious that we need to know more about ADHD, obesity and MBS in adolescents. The figures that are available on ADHD in adolescents seeking MBS range widely from 6% to 29% and outcome data beyond one year are lacking. More specific questions must also be addressed when adolescents with ADHD undergo MBS. First of all, the 2019 meta-analysis that found no difference in weight loss between adult patients with and without ADHD, at the same time found that patients with ADHD had significantly fewer follow-up visits after MBS than patients without ADHD.8 The currently available guidelines tell us to provide extra attention and care to young patients with psychiatric disorders. If the same patterns were to emerge in adolescents with ADHD, how could we possibly deliver high-quality follow-up care to patients who repeatedly do not attend appointments? We need to figure out the best way to deliver follow-ups to adolescents with ADHD after MBS, perhaps with the help of e-health technology. Another very important question is how to monitor and adjust ADHD medication after MBS in clinical settings. A substantial proportion of adolescents with ADHD undergoing MBS is likely to have medication as part of their ADHD treatment. Their medication needs could be altered after MBS, due to possible changes in uptake, so there is a requirement to monitor and possibly adjust the dosage.9 This requires co-operation between the paediatrician referring the adolescent to MBS and the paediatric psychiatrist who prescribed the psychostimulants. A third important point is that after MBS, there is an increased risk of developing alcohol dependence and adolescents with ADHD might be at particular risk. The primary reason for the increased risk of alcohol dependence after MBS is the noted alteration in alcohol uptake, and different procedures were said to pose different risks for increased consumption.10 A review by Spadola et al showed that there were other risk factors for developing alcohol dependence after MBS than just the type of procedure. These included younger age and having ADHD symptoms.10 When clinicians accept adolescents with ADHD for MBS, they must inform them and their parents or guardians about the increased risk of alcohol use disorder and offer them structured screening. Specialised clinics must be prepared to deliver safe and effective interventions for the substantial minority of adolescents who present for MBS and also have a diagnosis of ADHD or salient symptoms. So far, there is no evidence that patients with ADHD should be advised against undergoing MBS, but health care systems must be ready to offer long-term follow-up care that is tailored to the specific risks and needs seen in young patients with ADHD. The author has no conflicts of interest. Kajsa Järvholm