Treatment Of Attention-deficit/hyperactivity Disorder In Children Research Articles

Treatment of Aggressive ADHD in Children and Adolescents: Conceptualization and Treatment of Comorbid Behavior Disorders

Primary care physicians who treat attention-deficit/hyperactivity disorder (ADHD) may expect to encounter oppositional defiant disorder (ODD) in about half of patients with ADHD. Up to 20% of patients with ADHD may meet criteria for conduct disorder (CD), and a higher percentage will exhibit aggressiveness or other symptoms of CD without meeting full diagnostic criteria. Primary care physicians self-report more competence in managing ADHD alone than when it is accompanied by comorbid ODD or CD, even though the diagnostic and treatment considerations are similar. The empirical literature on normal and antisocial behavioral development provides insight into understanding how patients with comorbid disruptive behavior may differ from those with uncomplicated ADHD. Primary care physicians who are competent to diagnosis and treat ADHD may develop similar competence in managing patients with ADHD plus oppositional and/or aggressive behavior and, if allied with colleagues who provide specialized psychosocial treatment, may fill an important role in the overall management of complex cases.

Atomoxetine

Atomoxetine

An Open-Label Trial of Reboxetine in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder

The main aim of this study was to assess the effectiveness and tolerability of reboxetine, a selective norepinephrine reuptake inhibitor, in children and adolescents with attention-deficit/hyperactivity disorder (ADHD). Twenty children and adolescents, aged 6-16 (mean, 10.29; standard deviation, SD = 2.72) years, diagnosed with ADHD were enrolled in a 6-week open-label trial. Assessments included the ADHD Rating Scale (home version) and Conners' Parent Rating Scale-Revised, Short Version [CPRS-R (S)]. The dose of reboxetine was between 3 and 6 mg/day (mean, 4.41). A significant reduction in ADHD symptoms, as measured by CPRS-R (S), was observed. This reduction was significant after 2 weeks of treatment (p < 0.001). The oppositional symptoms were also reduced significantly (p < 0.05). Reboxetine was relatively well tolerated. The most common adverse effects were decreased appetite, constipation, sleep problems, and dry mouth. This open-label study suggests the efficacy of reboxetine in the treatment of ADHD in children and adolescents. Controlled studies in larger samples are needed to test the effectiveness of reboxetine in ADHD.

Risperidone treatment for ADHD in children and adolescents with bipolar disorder

Children and adolescents with bipolar disorder are also at high risk of having comorbid attention-deficit hyperactivity disorder (ADHD). The objective of this study was to estimate improvement in ADHD symptoms in children with bipolar disorder. This was an open-label, study of risperidone monotherapy for the treatment of pediatric bipolar disorder. Thirty-one children and adolescents 4-15 years of age (7.2 +/- 2.8 years) of both sexes (71%, N = 22 male) with pediatric bipolar disorder (YMRS score = 32.9 +/- 8.8) and ADHD (ADHD-RS score = 37.9 +/- 8.9) were included in these analyses. Improvement in ADHD symptoms was contingent on improvement in manic symptoms. Although both hyperactive/impulsive (-7.5 +/- 5.5.6, p < 0.05) and inattentive (-6.8 +/- 5.0, p < 0.05) ADHD symptoms were significantly improved with risperidone, improvement was modest, and only 29% of subjects (N = 6) showed a 30% reduction in ADHD rating scale scores and had a CGI-I </= 2. These results suggest that that treatment with risperidone is associated with tangible but generally modest improvement of symptoms of ADHD in children with bipolar disorder.

Switching from Neurostimulant Therapy to Atomoxetine in Children and Adolescents with Attention-Deficit Hyperactivity Disorder

This review provides practical information on and clinical reasons for switching children and young people with attention-deficit hyperactivity disorder (ADHD) from neurostimulants to atomoxetine, detailing currently available evidence, and switching options. The issue is of particular relevance following recent guidance from the National Institute for Health and Clinical Excellence and European ADHD guidelines endorsing the use of atomoxetine, along with the stimulants methylphenidate and dexamphetamine, in the management of ADHD in children and adolescents in the UK. The selective norepinephrine (noradrenaline) reuptake inhibitor, atomoxetine, is a non-stimulant drug licensed for the treatment of ADHD in children and adolescents, and in adults who have shown a response in childhood. Following the once-daily morning dose, its therapeutic effects extend through the waking hours, into late evening, and in some patients, through to early the next morning. Atomoxetine may be considered for patients who are unresponsive or incompletely responsive to stimulant treatment, have co-morbid conditions (e.g. tics, anxiety, depression), and have sleep disturbances or eating problems, for patients in whom stimulants are poorly tolerated, and for situations where there is potential for drug abuse or diversion. Atomoxetine has been shown to be effective in relapse prevention and there is suggestion that atomoxetine may have a positive effect on global functioning; specifically health-related quality of life, self-esteem, and social and family functioning. According to one study, approximately 50% of non-responders to methylphenidate will respond to atomoxetine therapy and approximately 75% of responders to methylphenidate will also respond to atomoxetine. Atomoxetine may be initiated by a schedule of dose increases and cross-tapering with methylphenidate. A slow titration schedule with divided doses minimizes the impact of adverse events within the first several weeks of treatment. Atomoxetine may be co-administered with methylphenidate during the switching period without undue concern for adverse events, such as cardiovascular effects (although monitoring of blood pressure and heart rate is necessary). Atomoxetine may be discontinued abruptly and patients may miss the occasional dose without rebound effects or discontinuation syndrome. A trial period of at least 6-8 weeks, perhaps longer, is recommended before evaluation of the overall tolerability and efficacy of atomoxetine. We conclude that patients with ADHD can be switched from neurostimulants, specifically methylphenidate, to atomoxetine, and may benefit from symptom improvement.

When ADHD and substance use disorders intersect: Relationship and treatment implications

There has been increasing interest in the overlap between attention-deficit/hyperactivity disorder (ADHD) and substance use disorders (SUDs). In this report, we describe the developmental relationship between ADHD and SUDs. ADHD alone and in combination with co-occurring psychopathology is a risk factor for the development of SUDs in adulthood. Conversely, approximately one fifth of adults with SUDs have ADHD. Pharmacotherapeutic treatment of ADHD in children reduces the risk for later cigarette smoking and SUDs in adulthood. In contrast, medication treatment alone of adults with ADHD and current SUD is inadequate for both ADHD and SUD. Stimulant diversion continues to be of concern, particularly in older adolescents and young adults.

Enhancement of atomoxetine serum levels by co-administration of paroxetine

Attention deficit hyperactivity disorder (ADHD) is one of the most common psychiatric disorders in childhood and adolescence. ADHD is characterized by the inability to appropriately modulate attention and/or impulse control and hyperactivity, resulting in social, academic and occupational underachievement. With a prevalence of 3–5%, ADHD is one of the most frequently seen disorders in child and adolescent psychiatry. Medication represents a major component of a multi-modal treatment plan. Treatment with stimulants is the drug therapy of first choice in ADHD of adulthood. While methylphenidate is mainly used, one third of the patients do not adequately respond to this drug. These patients may profit from a change to treatment with dual active antidepressants. Atomoxetine is a potent and selective inhibitor of the presynaptic norepinephrine transporter that influences not only norepinephrine but also dopamine concentration. It is used for the treatment of ADHD in children, adolescents and adults. The systemic clearance of atomoxetine involves three oxidative metabolic pathways, whereas the aromatic ring-hydroxylation results in the formation of the primary oxidative metabolite of atomoxetine, 4-hydroxyatomoxetine, which is then glucoronidated and excreted in urine. The formation of 4-hydroxyatomoxetine is mediated by cytochrome P450 (CYP), in particular 2D6 (Sauer et al., 2005). Variations in plasma atomoxetine exposures can occur because of genetic variation or as a consequence of co-administration with drugs that inhibit CYP2D6. Very recently Michelson et al. (2007) showed significant differences in serum plasma levels of atomoxetine between CYP2D6 extensive metabolizers (EM) and poor metabolizers (PM). Differences in the CYP2D6 genotype and phenotype as well as pharmacokinetic interventions can potentially affect the clinical profile of atomoxetine as seen in efficacy and tolerability of the drug whereas the effect of potent CYP2D6 inhibition on the pharmacokinetics of atomoxetine has rarely been investigated. Belle et al. (2002) showed …

Drug and non-drug treatments of children with ADHD and tic disorders

To review the treatment of ADHD in children with chronic tic disorders. Tic disorders are relatively common in school-age children and range from mild to severe. Children with mild tics may not require medication for the treatment of tics. The co-occurrence of attention deficit hyperactivity disorder (ADHD) and disruptive behavior are common in children with tic disorders and may be associated with significant morbidity. We conducted a literature search to identify reports of tics as an adverse effect to stimulant medication, the treatment of children with ADHD and tics as well as novel treatments that have been proposed for the treatment of ADHD in children with tic disorders. The preponderance of evidence suggests that stimulant medications are safe and effective in the treatment of children with ADHD and tic disorders. A minority of children with tic disorders may show a worsening of tics or not tolerate stimulants for other reasons. The growing list of non-stimulants provides options for clinicians and parents of these children. Treatment planning for children with ADHD and tic disorders involves careful discussion with parents on choosing the best course of action. Stimulants should be part of this discussion. More study is needed on non-pharmacological approaches to the treatment of tics and ADHD in this population.

Methylphenidate reduces impulsive behaviour in juvenile Wistar rats, but not in adult Wistar, SHR and WKY rats

Impulsivity is a core symptom of attention deficit/hyperactivity disorder (ADHD). The spontaneously hypertensive rats (SHR) is a strain commonly used as an animal model of ADHD. However, there is no clear evidence that psychostimulants, which are used for treatment of ADHD, reduce impulsivity in SHR. Because ADHD mainly affects children, it may be relevant to study psychostimulants on juvenile animals. Using tolerance to delay of reward as index of impulsivity, the effects of methylphenidate were assessed in adult SHR, Wistar Kyoto (WKY) and Wistar rats and in juvenile Wistar rats. Animals were trained in a T-maze to choose between a small-but-immediate and a large-but-delayed reward. Adult SHR, WKY and Wistar rats were compared for their ability to tolerate a 15-s delay. The effect of methylphenidate on the tolerance to a 30-s delay was studied in adult rats of the three strains and in juvenile (4.5 to 6.5-week-old) Wistar rats. In adult rats, the waiting ability was lower in SHR than in control strains. Waiting ability was improved by methylphenidate (3 and 5 mg/kg) in juveniles, but not by methylphenidate (3 mg/kg) in adults. These data support the idea that SHR are more impulsive than control strains. However, at the dose studied, methylphenidate fails to improve tolerance to delay in adult rats whatever the strain used. The reduction of impulsivity induced by methylphenidate in juvenile Wistar rats indicates that juvenile animals may be suitable for testing the therapeutic potential of drugs intended to the treatment of ADHD in children.

Quality of Life Assessment in Adult Patients With Attention-deficit/Hyperactivity Disorder Treated With Atomoxetine

Attention-deficit/hyperactivity disorder (ADHD) has its onset during childhood and is estimated to affect 3% to 7% of school-aged children. Unfortunately, the disorder frequently persists into adult life. The burden of this disorder is considerable and is often characterized by academic (or occupational) impairment and dysfunction within the family and society. Despite the existence of research demonstrating the effects of ADHD on certain aspects of life, the clinical trials of treatments for this disorder have focused primarily on efficacy and safety. Atomoxetine was approved in the United States in November 2002 for the treatment of ADHD in children, adolescents, and adults. The present study uses data from a clinical trial of atomoxetine in adult patients with ADHD that incorporated a measure of health-related quality of life (the Medical Outcomes Study 36-item short-form health survey [SF-36]) as part of the overall assessment of the success of this relatively new treatment. The primary outcome measure for ADHD symptoms was the Conners Adult ADHD Rating Scale-Investigator Rated: Screening Version (CAARS) ADHD total symptom score. In agreement with previous studies, adult patients with ADHD treated with atomoxetine at typical doses showed significant amelioration of ADHD symptoms, as measured on the CAARS. At baseline, the measures of overall mental health (one aspect of quality of life) of adult patients with ADHD were below the average level, as measured on the SF-36. Treatment with atomoxetine significantly improved the measures of mental health and ameliorated the ADHD symptoms. In addition, the 2 measures were correlated. These data suggest that pharmacological intervention with atomoxetine not only ameliorates ADHD symptoms in adult patients but also improves their perceived quality of life.

Efficacy and Safety of Dexmethylphenidate Extended-Release Capsules in Children With Attention-Deficit/Hyperactivity Disorder

The efficacy and safety of dexmethylphenidate extended release (d-MPH-ER) was compared to placebo in pediatric patients with attention-deficit/hyperactivity disorder (ADHD). This multicenter, randomized, double-blind, placebo-controlled, parallel-group, two-phase study included 97 patients (ages 6-17 years) with DSM-IV-defined ADHD. The study was carried out between 2001 and 2003. After a 2-week evaluation phase, patients were randomized to d-MPH-ER or placebo for 7 weeks. Flexible d-MPH-ER dosing (30 mg/day) was permitted for 5 weeks, then patients remained on their optimal dose during the last 2 study weeks. The primary efficacy measure was change from baseline to final rating in Conners ADHD/DSM-IV Scale-Teacher version (CADS-T) total subscale score. Secondary efficacy variables included changes from baseline to final visit in CADS-T Inattentive and Hyperactive-Impulsive subscale scores, CADS-P DSM-IV total subscale score and Inattentive and Hyperactive-Impulsive subscale scores, Clinical Global Impressions-Improvement (CGI-I) and CGI-Severity (CGI-S) scale scores, and Child Health Questionnaire Parent Form 50 scores. d-MPH-ER improved CADS-T total scores significantly compared with placebo (p <.001), and 67.3% of d-MPH-ER patients were rated much improved or very much improved on CGI-I at final visit versus 13.3% of placebo patients (p <.001). More patients taking d-MPH-ER (49.1%) than placebo (25.5%) spontaneously reported adverse events suspected as drug related. Once-daily d-MPH-ER was more effective than placebo in the treatment of ADHD in children and adolescents.

Comparison of Parent and Teacher Reports of Attention-Deficit/Hyperactivity Disorder Symptoms from Two Placebo-Controlled Studies of Atomoxetine in Children

The validity of parent reports regarding children's attention-deficit/hyperactivity disorder (ADHD) symptoms has been questioned. This study assessed whether parent reports were as sensitive as teacher reports to document change in ADHD symptoms during clinical trials with atomoxetine. Data were compared from two randomized, double-blind, placebo-controlled clinical trials of atomoxetine using different versions (parent or teacher) of the same rating scale (Attention-Deficit/Hyperactivity Disorder Rating Scale-IV [parent or teacher] Version: Investigator Administered and Scored - ADHD RS). Exclusion criteria included history of bipolar disorder, psychosis, seizures, alcohol abuse, or positive drug screen. Patients (6-16 years old) were treated with atomoxetine (titrated to a maximum dose of 1.8 mg/kg/day) administered once daily for up to 7 weeks. Parent and teacher ratings were compared using an analysis of covariance (ANCOVA) model. The analysis (n = 318) showed that treatment effects (mean change, baseline to endpoint) were similar between parent and teacher ratings (total, p = .762; inattention, p = .519; hyperactive/impulsive, p = .955). Effect sizes also were similar based on total scores (parent ratings = .69; teacher ratings = .63). Parent reports are as sensitive as teacher reports in assessing the efficacy of long-acting pharmacologic treatment for ADHD in children during clinical trials using the nonstimulant atomoxetine.

The Texas Children's Medication Algorithm Project: Revision of the Algorithm for Pharmacotherapy of Attention-Deficit/Hyperactivity Disorder

In 1998, the Texas Department of Mental Health and Mental Retardation developed algorithms for medication treatment of attention-deficit/hyperactivity disorder (ADHD). Advances in the psychopharmacology of ADHD and results of a feasibility study of algorithm use in community mental health centers caused the algorithm to be modified and updated. We convened a consensus conference of academic clinicians and researchers, practicing clinicians, administrators, consumers, and families to revise the algorithms for the pharmacotherapy of ADHD itself as well as ADHD with specific comorbid disorders. New research was reviewed by national experts, and rationales were provided for proposed changes and additions to the algorithms. The changes to the algorithms were discussed and approved both by the national experts and experienced clinicians from the Texas public mental health system. The panel developed consensually agreed-upon algorithms for ADHD with and without comorbid disorders. The major changes included elimination of pemoline as a treatment option, adding atomoxetine to the algorithm, and refining guidelines for treating ADHD with comorbid depression, aggressive behaviors, and tic disorders. Medication algorithms for ADHD can be modified to keep abreast of developments in the field. Although these evidence- and consensus-based treatment recommendations may be a useful approach to guide the treatment of ADHD in children, additional research is needed to determine how these algorithms can be used to maximally benefit child outcomes.

New Alcoholism, ADHD Treatments Win Approval From FDA

New Alcoholism, ADHD Treatments Win Approval From FDA

Methylphenidate Skin Patch Approved for ADHD

Methylphenidate Skin Patch Approved for ADHD

P.7.a.003 Divalproex sodium for the treatment of irritability in autism

The efficacy and safety of dexmethylphenidate extended release (d-MPH-ER) was compared to placebo in pediatric patients with attention-deficit/hyperactivity disorder (ADHD).This multicenter, randomized, double-blind, placebo-controlled, parallel-group, two-phase study included 97 patients (ages 6-17 years) with DSM-IV-defined ADHD. The study was carried out between 2001 and 2003. After a 2-week evaluation phase, patients were randomized to d-MPH-ER or placebo for 7 weeks. Flexible d-MPH-ER dosing (30 mg/day) was permitted for 5 weeks, then patients remained on their optimal dose during the last 2 study weeks. The primary efficacy measure was change from baseline to final rating in Conners ADHD/DSM-IV Scale-Teacher version (CADS-T) total subscale score. Secondary efficacy variables included changes from baseline to final visit in CADS-T Inattentive and Hyperactive-Impulsive subscale scores, CADS-P DSM-IV total subscale score and Inattentive and Hyperactive-Impulsive subscale scores, Clinical Global Impressions-Improvement (CGI-I) and CGI-Severity (CGI-S) scale scores, and Child Health Questionnaire Parent Form 50 scores.d-MPH-ER improved CADS-T total scores significantly compared with placebo (p <.001), and 67.3% of d-MPH-ER patients were rated much improved or very much improved on CGI-I at final visit versus 13.3% of placebo patients (p <.001). More patients taking d-MPH-ER (49.1%) than placebo (25.5%) spontaneously reported adverse events suspected as drug related.Once-daily d-MPH-ER was more effective than placebo in the treatment of ADHD in children and adolescents.

Psychotherapy for Children and Adolescents: Evidence-Based Treatments and Case Examples

Psychotherapy for Children and Adolescents: Evidence-Based Treatments and Case Examples

L’atomoxétine : un nouveau traitement du trouble déficitaire de l’attention/hyperactivité de l’enfant et de l’adolescent

L’atomoxétine : un nouveau traitement du trouble déficitaire de l’attention/hyperactivité de l’enfant et de l’adolescent

Atomoxetine: a new pharmacotherapeutic approach in the management of attention deficit/hyperactivity disorder

Atomoxetine is a novel, non-stimulant, highly selective noradrenaline reuptake inhibitor that has been studied for use in the treatment of attention deficit/hyperactivity disorder (ADHD). Data from clinical trials show it...

Atomoxetine for the treatment of attention-deficit/hyperactivity disorder

Atomoxetine is a selective noradrenaline reuptake inhibitor that has been studied for use in the treatment of attention-deficit/hyperactivity disorder (ADHD). In vitro, ex vivo and in vivo studies have shown that atomoxetine is a highly selective antagonist of the presynaptic norepinephrine transporter with little or no affinity for other noradrenergic receptors or other neurotransmitter transporters or receptors. So far, two open-label and seven randomised, double-blind, placebo-controlled, clinical trials have been published, six in youths and three in adults. Each of these trials has shown a positive response as measured by the primary efficacy measures, the ADHD-IV Rating Scale (ADHD RS) or the Conners Adult ADHD Rating Scale (CAARS). Atomoxetine has generally been well tolerated. The most common treatment-related adverse event was decreased appetite. Atomoxetine shows no abuse potential and is not a controlled substance in the US. In November of 2002 the FDA approved atomoxetine for use in the US for the treatment of ADHD in children, adolescents and adults. Atomoxetine is the first nonstimulant approved by the FDA for the treatment of ADHD and the first medication approved for the treatment of adult ADHD.