Attention 2.0 Professional Edition, Summer 2010

The Latest Research

Factors associated with atomoxetine efficacy for treatment of attention-deficit/hyperactivity disorder in children and adolescents
Scott, Nakia Gray; Ripperger-Suhler, Jane; Rajab, M. Hasan; Kjar, Dean.
Journal of Child and Adolescent Psychopharmacology, June 2010, v20 n3, pp. 197-203.

OBJECTIVES: The aims of this study were to determine if relationships exist between the efficacy of atomoxetine for treatment of attention-deficit/hyperactivity disorder (ADHD) and demographic characteristics, specific co-morbid diagnoses, subtype of ADHD, and/or additional use of a stimulant medication.
METHOD: A retrospective chart review was performed using data from an institutional electronic medical record system. Children aged 5-17 years who were diagnosed with ADHD and prescribed atomoxetine were included; 432 study subjects were categorized as treatment success (TS), treatment failure (TF), or undetermined. Co-morbid diagnoses, demographic factors, subtype of ADHD, and additional use of stimulant medications were examined for association with TS.
RESULTS: A total of 88 children were categorized as TS, 197 as TF, and 147 as undetermined. More subjects in the TS group were receiving stimulant medication in addition to the atomoxetine than in the TF group (p = 0.0319; 95% Wald confidence interval [CI], 1.064-3.972). There was no significant difference between groups for any demographic characteristic, the presence of any co-morbid diagnosis, or type of ADHD. In particular, the presence of anxiety or depression was not associated with a response to atomoxetine.
CONCLUSION: Children who were prescribed a stimulant medication in addition to atomoxetine had better outcomes in treating ADHD than those receiving only atomoxetine.

Inconsistent Self-Report of Delinquency by Adolescents and Young Adults with ADHD
Sibley, Margaret H.; Pelham, William E.; Molina, Brooke S. G.; Waschbusch, Daniel A.; et al.
Journal of Abnormal Child Psychology, July 2010, v38 n5, pp. 645-656 [March 22, 2010, Online Early]

The purpose of the current study was to test the ability of adolescents and young adults with childhood ADHD to reliably self-report delinquency history. Data were examined from the Pittsburgh ADHD Longitudinal Study (PALS), a follow-up study of children diagnosed with ADHD between 1987 and 1996. Self-report of lifetime delinquency history was compared to concurrent parent-report and to self-report 1 year later. Participants included 313 male probands and 209 demographically similar comparison individuals without ADHD. Results indicated that adolescents and young adults with childhood ADHD were more likely than comparison participants to fail to report delinquent acts reported by a parent and to recant acts they endorsed 1 year earlier. This trend was most apparent for acts of mild to moderate severity. After controlling for several covariates, current ADHD symptom severity and parent-report of the participant's tendency to lie predicted reporting fewer delinquent acts than one's parent. Current ADHD symptom severity also predicted more recanting of previously endorsed acts. Based on these findings, several recommendations are made for the assessment of delinquency history in adolescents and young adults with childhood ADHD.

Parental adherence to clinical recommendations in an ADHD evaluation clinic
Dreyer, A. Samantha; O'Laughlin, Liz; Moore, Janna; Milam, Zachary.
Journal of Clinical Psychology, June 24, 2010, Online Early.

The present study examined perceived barriers to parental adherence with child psychological assessment recommendations. Eighty caregivers of children referred to an attention-deficit/hyperactivity disorder (ADHD) evaluation clinic completed a telephone interview 4 to 6 weeks after receiving evaluation feedback. Caregivers reported adherence to 81.5% of recommendations and were equally likely to engage in self-help recommendations (i.e., information on ADHD) and those for professional-nonpsychological services (i.e., medication consultation). Caregivers were least likely to follow through on recommendations for psychological services (e.g., parental behavior training, individual therapy for children with symptoms of anxiety/depression). Higher rather than lower levels of parenting stress were associated with greater adherence. The most commonly reported barriers were lack of time and perceptions that the child's teacher was uncooperative with implementing school-based recommendations. © 2010 Wiley Periodicals, Inc. J Clin Psychol 66:1-20, 2010.

Meditation therapies for attention-deficit/hyperactivity disorder (ADHD)
Krisanaprakornkit, Thawatchai; Ngamjarus, Chetta; Witoonchart, Chartree; Piyavhatkul, Nawanant.
Cochrane Database of Systematic Reviews, 2010, Issue 6, CD006507

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is one of the most common developmental disorders experienced in childhood and can persist into adulthood. The disorder has early onset and is characterized by a combination of overactive, poorly modulated behavior with marked inattention. In the long term it can impair academic performance, vocational success and social-emotional development. Meditation is increasingly used for psychological conditions and could be used as a tool for attentional training in the ADHD population.
OBJECTIVES: To assess the effectiveness of meditation therapies as a treatment for ADHD.
SEARCH STRATEGY: Our extensive search included: CENTRAL, MEDLINE, EMBASE, CINAHL, ERIC, PsycINFO, C2-SPECTR, dissertation abstracts, LILACS, Virtual Health Library (VHL) in BIREME, Complementary and Alternative Medicine specific databases, HSTAT, Informit, JST, Thai Psychiatric databases and ISI Proceedings, plus grey literature and trial registries from inception to January 2010.
SELECTION CRITERIA: Randomized controlled trials that investigated the efficacy of meditation therapy in children or adults diagnosed with ADHD.
DATA COLLECTION AND ANALYSIS: Two authors extracted data independently using a pre-designed data extraction form. We contacted study authors for additional information required. We analyzed data using mean difference (MD) to calculate the treatment effect. The results are presented in tables, figures and narrative form.
MAIN RESULTS: Four studies, including 83 participants, are included in this review. Two studies used mantra meditation while the other two used yoga compared with drugs, relaxation training, non-specific exercises and standard treatment control. Design limitations caused high risk of bias across the studies. Only one out of four studies provided data appropriate for analysis. For this study there was no statistically significant difference between the meditation therapy group and the drug therapy group on the teacher rating ADHD scale (MD -2.72, 95% CI -8.49 to 3.05, 15 patients). Likewise, there was no statistically significant difference between the meditation therapy group and the standard therapy group on the teacher rating ADHD scale (MD -0.52, 95% CI -5.88 to 4.84, 17 patients). There was also no statistically significant difference between the meditation therapy group and the standard therapy group in the distraction test (MD -8.34, 95% CI -107.05 to 90.37, 17 patients).
AUTHORS' CONCLUSIONS: As a result of the limited number of included studies, the small sample sizes and the high risk of bias, we are unable to draw any conclusions regarding the effectiveness of meditation therapy for ADHD. The adverse effects of meditation have not been reported. More trials are needed.

Exposure to Polyfluoroalkyl Chemicals and Attention Deficit Hyperactivity Disorder in U.S. Children Aged 12-15 Years
Hoffman, Kate; Webster, Thomas F.; Weisskopf, Marc G.; Weinberg, Janice; Vieira, Verónica M.
Environmental Health Perspectives, June 15, 2010, Online Early.
INTRODUCTION: Polyfluoroalkyl chemicals (PFCs) have been widely used in consumer products. Exposures in the U.S. and world populations are widespread. PFC exposures have been linked previously to various health impacts, and data in animals suggest that PFCs may be potential developmental neurotoxicants.
OBJECTIVES: We evaluated the associations between exposures to four PFCs and parental report of diagnosis of attention deficit hyperactivity disorder (ADHD).
METHODS: Data were obtained from the National Health and Nutrition Examination Survey (NHANES) 1999-2000 and 2003-2004 for children aged 12-15 years. Parental report of a previous diagnosis by a doctor or healthcare professional of ADHD in the child was the primary outcome measure. Perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), perfluorononanoic acid (PFNA), and perfluorohexane sulfonic acid (PFHxS) levels were measured in serum samples from each child.
RESULTS: Of the 586 children in the sample, 51 reported a diagnosis of ADHD. When PFOS was treated as a continuous predictor, a 1.03 fold increased odds was observed for each ìg/L increase in serum PFOS after adjustment for confounding (95% CI 1.01-1.05). There were also significant dose response relationships between PFOA and PFHxS levels and ADHD (OR=1.12; 95% CI 1.01-1.23 and OR=1.06; 95% CI 1.02-1.11 respectively). Similarly, children with higher PFNA levels were more likely to have ADHD (OR=1.32; 95% CI 0.86-2.02).
CONCLUSIONS: Our results, using cross-sectional data, are consistent with increased odds of ADHD in children with higher serum PFC levels. Given the extremely prevalent exposure to PFCs, follow-up of these data with cohort studies is needed.

A Naturalistic 10-Year Prospective Study of Height and Weight in Children with Attention-Deficit Hyperactivity Disorder Grown Up: Sex and Treatment Effects
Biederman, Joseph; Spencer, Thomas J.; Monuteaux, Michael C.; Faraone, Stephen V. 
Journal of Pediatrics, June 7, 2010, Online Early.
OBJECTIVE: To assess the effect of attention-deficit/hyperactivity disorder (ADHD) and its treatment on growth outcomes in children followed into adulthood.
STUDY DESIGN: Two identically designed, longitudinal, case-control studies of males and females with and without ADHD were combined; 124 and 137 control and subjects with ADHD, respectively, provided growth information at the 10- to 11-year follow-up. We used linear growth curve models to estimate the effect of time on change in height and whether this effect differed by sex and ADHD status. We also examined the effect of stimulant treatment on growth outcomes.
RESULTS: We found no evidence that ADHD was associated with trajectories of height over time or differences at follow-up in any growth outcomes. Similarly, we found no evidence that stimulant treatment was associated with differences in growth. However, among subjects with ADHD, major depression was associated with significantly larger weight in females and smaller height in males.
CONCLUSIONS: Our results do not support an association between deficits in growth outcomes and either ADHD or psychostimulant treatment for ADHD. These findings extend the literature on this topic into young adulthood and should assist clinicians and parents in formulating treatment plans for children with ADHD.

Chiropractic care for paediatric and adolescent Attention-Deficit/Hyperactivity Disorder: A systematic review
Karpouzis, Fay; Bonello, Rod; Pollard, Henry.
Chiropractic & Osteopathy, June 2, 2010, 18(1):13

BACKGROUND: Psychostimulants are first line of therapy for paediatric and adolescent AD/HD. The evidence suggests that up to 30% of those prescribed stimulant medications do not show clinically significant outcomes. In addition, many children and adolescents experience side-effects from these medications. As a result, parents are seeking alternate interventions for their children. Complementary and alternative medicine therapies for behavioural disorders such as AD/HD are increasing with as many as 68% of parents having sought help from alternative practitioners, including chiropractors.
OBJECTIVE: The review seeks to answer the question of whether chiropractic care can reduce symptoms of inattention, impulsivity and hyperactivity for paediatric and adolescent AD/HD. METHODS: Electronic databases (Cochrane CENTRAL register of Controlled Trials, Cochrane Database of Systematic reviews, MEDLINE, PsycINFO, CINAHL, Scopus, ISI Web of Science, Index to Chiropractic Literature) were searched from inception until July 2009 for English language studies for chiropractic care and AD/HD. Inclusion and exclusion criteria were applied to select studies. All randomised controlled trials were evaluated using the Jadad score and a checklist developed from the CONSORT (Consolidated Standards of Reporting Trials) guidelines.
RESULTS: The search yielded 58 citations of which 22 were intervention studies. Of these, only three studies were identified for paediatric and adolescent AD/HD cohorts. The methodological quality was poor and none of the studies qualified using inclusion criteria.
CONCLUSIONS: To date there is insufficient evidence to evaluate the efficacy of chiropractic care for paediatric and adolescent AD/HD. The claim that chiropractic care improves paediatric and adolescent AD/HD, is only supported by low levels of scientific evidence. In the interest of paediatric and adolescent health, if chiropractic care for AD/HD is to continue, more rigorous scientific research needs to be undertaken to examine the efficacy and effectiveness of chiropractic treatment. Adequately-sized RCTs using clinically relevant outcomes and standardised measures to examine the effectiveness of chiropractic care verses no-treatment/placebo control or standard care (pharmacological and psychosocial care) are needed to determine whether chiropractic care is an effective alternative intervention for paediatric and adolescent AD/HD.

Conditioned Placebo Dose Reduction: A New Treatment in Attention-Deficit Hyperactivity Disorder?
Sandler, Adrian D.; Glesne, Corrine E.; Bodfish, James W. 
Journal of Developmental and Behavioral Pediatrics, June 2010, v31 n5, pp. 369-375 [May 20, 2010, Online Early]

OBJECTIVE: This study examined if pairing a placebo with stimulant medication produces a placebo response that allows children with attention-deficit hyperactivity disorder (ADHD) to be maintained on a lower dose of stimulant medication. The primary aim was to determine the efficacy, side effects, and acceptability of a novel conditioned placebo dose reduction procedure.
METHOD: Participants included 99 children ages 6 to 12 years with ADHD. After an initial double-blind dose finding to identify optimal dose of mixed amphetamine salts, subjects were randomly assigned to 1 of 3 treatments of 8-week duration: (a) conditioned placebo dose reduction condition (50% reduced dose/placebo [RD/P]) or (b) a dose reduction only condition (RD) or (c) a no reduction condition (full dose). The innovative conditioned placebo dose reduction procedure involved daily pairing of mixed amphetamine salts dose with a visually distinctive placebo capsule administered in open label, with full disclosure of placebo use to subjects and parents.
RESULTS: Seventy children completed the study. There were no differences in subject retention among the 3 groups. Most subjects in the RD/P group remained stable during the treatment phase, whereas most in the RD group deteriorated. There was no difference in control of ADHD symptoms between the RD/P group and the full dose group, and both RD/P and full dose groups showed better ADHD control than the RD group. Treatment emergent side effects were lowest in the RD/P group.
CONCLUSION: Pairing placebos with stimulant medication elicits a placebo response that allows children with ADHD to be effectively treated on 50% of their optimal stimulant dose.

Detection of feigned ADHD in college students
Sollman, Myriam J.; Ranseen, John D.; Berry, David T. R.
Psychological Assessment, June 2010, v22 n2, pp. 325-335.
Significant motivations and incentives exist for young-adult students to seek a diagnosis of attention-deficit/hyperactivity disorder (ADHD). With ADHD information readily accessible on the Internet, today's students are likely to be symptom educated prior to evaluation. This may result in false-positive diagnoses, particularly when students are motivated to convey symptoms. We evaluated the utility of ADHD symptom checklists, neurocognitive tests, and measures initially developed to detect feigned neurocognitive or psychiatric dysfunction (symptom validity tests [SVTs]). The performance of 31 undergraduates financially motivated and coached about ADHD via Internet-derived information was compared to that of 29 ADHD undergraduates following medication washout and 14 students not endorsing symptomatology. Results indicated malingerers readily produced ADHD-consistent profiles. Symptom checklists, including the ADHD Rating Scale and Conners's Adult ADHD Rating Scale-Self-Rating Form: Long, were particularly susceptible to faking. Conners's Continuous Performance Test-II findings appeared more related to motivation than condition. Promising results were seen with all cognitive SVTs (Test of Memory Malingering [TOMM], Digit Memory Test, Letter Memory Test, and Nonverbal-Medical Symptom Validity Test), particularly TOMM Trial 1 when scored using Trial 2 criteria. All SVTs demonstrated very high specificity for the ADHD condition and moderate sensitivity to faking, which translated into high positive predictive values at rising base rates of feigning. Combining 2 or more failures resulted in only modest declines in sensitivity but robust specificity. Results point to the need for a thorough evaluation of history, cognitive and emotional functioning, and the consideration of exaggerated symptomatology in the diagnosis of ADHD. (PsycINFO Database Record © 2010 APA, all rights reserved).

A Randomized, Single-Blind, Substitution Study of OROS Methylphenidate (Concerta) in ADHD Adults Receiving Immediate Release Methylphenidate
Spencer, Thomas J.; Mick, Eric; Surman, Craig B. H.; Hammerness, Paul; et al.
Journal of Attention Disorders, May 21, 2010, Online Early.

OBJECTIVE: The main aim of this study was to examine the efficacy, tolerability, and compliance of an extended-release formulation of methylphenidate (OROS-MPH) in adults with ADHD receiving immediate-release methylphenidate (IR-MPH).
METHOD: Participants were outpatient adults with ADHD who were stable on IR-MPH-administered TID. Participants were randomized (4:1) to equipotent doses of OROS-MPH or to continue IR-MPH and were assessed weekly for 6 weeks with the Adult ADHD Investigator System Symptom Report Scale (AISRS). RESULTS: Randomization of 53 IR-MPH responders to IR- or OROS-MPH had no effect on AISRS score at endpoint (11.2 +/- 6.9 vs. 10.7 +/- 5.1, p = .8). Participants stabilized on IR-MPH and switched to OROS-MPH remained satisfied over 71% of the time. However, the IR-MPH group missed more doses (7.3 +/- 6.8 vs. 3.3 +/- 4.2, p = .02) than the OROS-MPH group.
CONCLUSION: Findings showed that adults with ADHD can be successfully switched from an effective regimen of IR-MPH TID to once-daily OROS-MPH. Results also demonstrated better compliance with OROS-MPH than with IR-MPH treatment.

Attention-Deficit/Hyperactivity Disorder and Urinary Metabolites of Organophosphate Pesticides
Bouchard, Maryse F.; Bellinger, David C.; Wright, Robert O.; Weisskopf, Marc G.
Pediatrics, May 17, 2010, Online Early.
OBJECTIVE: The goal was to examine the association between urinary concentrations of dialkyl phosphate metabolites of organophosphates and attention-deficit/hyperactivity disorder (ADHD) in children 8 to 15 years of age.
METHODS: Cross-sectional data from the National Health and Nutrition Examination Survey (2000-2004) were available for 1139 children, who were representative of the general US population. A structured interview with a parent was used to ascertain ADHD diagnostic status, on the basis of slightly modified criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
RESULTS: One hundred nineteen children met the diagnostic criteria for ADHD. Children with higher urinary dialkyl phosphate concentrations, especially dimethyl alkylphosphate (DMAP) concentrations, were more likely to be diagnosed as having ADHD. A 10-fold increase in DMAP concentration was associated with an odds ratio of 1.55 (95% confidence interval: 1.14-2.10), with adjustment for gender, age, race/ethnicity, poverty/income ratio, fasting duration, and urinary creatinine concentration. For the most-commonly detected DMAP metabolite, dimethyl thiophosphate, children with levels higher than the median of detectable concentrations had twice the odds of ADHD (adjusted odds ratio: 1.93 [95% confidence interval: 1.23-3.02]), compared with children with undetectable levels.
CONCLUSIONS: These findings support the hypothesis that organophosphate exposure, at levels common among US children, may contribute to ADHD prevalence. Prospective studies are needed to establish whether this association is causal.

ADHD Across Cultures: Is There Evidence for a Bidimensional Organization of Symptoms?
Bauermeister, Jose J.; Canino, Glorisa; Polanczyk, Guilherme; Rohde, Luis A.
Journal of Clinical Child and Adolescent Psychology, May 2010, v39 n3, pp. 362-372.
We examined the phenotypic expression of attention-deficit/hyperactivity disorder (ADHD) across cultures by assessing the factor/latent class structure of its core symptoms. We conducted a systematic review of the literature published from January 1987 to November 2008 using Medline and PsycINFO. We systematically reviewed 2,511 article abstracts, and 48 of these abstracts were included in this review. Research with school-age children from 15 countries including different samples, informants, and rating instruments supported a two-factor ADHD model consisting of inattention and combined hyperactivity and impulsivity. This model was not supported for preschool children. Cross-cultural equivalence for the two-factor model was suggested in some studies. Latent class analyses using parental data and more recent approaches like factor mixture modeling are generally consistent with factor analyses. These findings argue in favor of a cross-cultural validity of the syndrome. The implications of these findings for further research and classificatory systems in mental health like the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) are discussed.

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