Visual disorders with psychostimulants: A paediatric case report.

Methylphenidate- and amphetamine-based psychostimulants are the most common medications used to treat the symptoms of attention-deficit/hyperactivity disorder in children. Ocular side effects including dry eyes, mydriasis, accommodation disturbance, and blurry vision are listed in the product monograph but interestingly, are rarely reported in the paediatric literature. Our patient, a 9-year-old boy, presented a significant decrease in visual acuity secondary to accommodation disorder after being treated with methylphenidate hydrochloride controlled release (Biphentin) and lisdexamfetamine (Vyvanse). The unusual acute adverse effect, altered accommodation leading to a decline in visual acuity, emphasizes the importance of considering any change in vision following the introduction of psychostimulant medication as a potential adverse effect. This case highlights the importance of pharmacovigilance especially in paediatrics where data are lacking.

Erratum: Screening for disruptive behaviour problems in preschool children in primary health care settings.

[This corrects the article DOI: 10.1093/pch/pxx128.]

Screening for Disruptive Behaviour Problems in Preschool Children in Primary Health Care Settings.

Disruptive behaviour problems in preschool children are significant risk factors for, and potential components of, neurodevelopmental and mental health disorders. Some non-compliance, temper tantrums and aggression between two and five years of age are normal and transient. However, problematic levels of disruptive behaviour, specifically when accompanied by functional impairment and/or significant distress, should be identified because early intervention can improve outcome trajectories. This position statement provides an approach to early identification using clinical screening at periodic health examinations, followed by a systematic mental health examination that includes standardized measures. The practitioner should consider a range of environmental, developmental, family and parent-child relationship factors to evaluate the clinical significance of disruptive behaviours. Options within a management plan include regular monitoring accompanied by health guidance and parenting advice, referral to parent behaviour training as a core evidence-based intervention, and referral to specialty care for preschool children with significant disruptive behaviours, developmental or mental health comorbidities, or who are not responding to first-line interventions.

Screening for disruptive behaviour problems in preschool children in primary health care settings.

Disruptive behaviour problems in preschool children are significant risk factors for, and potential components of, neurodevelopmental and mental health disorders. Some noncompliance, temper tantrums and aggression between 2 and 5 years of age are normal and transient. However, problematic levels of disruptive behaviour, specifically when accompanied by functional impairment and/or significant distress, should be identified because early intervention can improve outcome trajectories. This position statement provides an approach to early identification using clinical screening at periodic health examinations, followed by a systematic mental health examination that includes standardized measures. The practitioner should consider a range of environmental, developmental, family and parent-child relationship factors to evaluate the clinical significance of disruptive behaviours. Options within a management plan include regular monitoring, accompanied by health guidance and parenting advice, referral to parent behaviour training as a core evidence-based intervention, and referral to specialty care for preschool children with significant disruptive behaviours, developmental or mental health comorbidities, or who are not responding to first-line interventions.

Persistent Handwriting Difficulties in Children With ADHD After Treatment With Stimulant Medication.

OBJECTIVE: Children with ADHD often present with handwriting difficulties. However, the extent to which motor and attention skills influence performance in this group has not yet been explored. The objective of this study was to examine the factors associated with change in handwriting performance. METHOD: This study examines the factors associated with change in handwriting performance of 49 children newly diagnosed with ADHD (mean age = 8.4 [SD=1.3] years) prior to and 3 months following use of a stimulant medication. RESULTS: Handwriting legibility and speed improved significantly at follow-up evaluation. However, most of the children with legibility difficulties at baseline continued to demonstrate difficulties when evaluated 3 months after initiation of medication. Change in handwriting legibility was best determined by improvements in visual-motor integration skills (ß = 0.07-0.10; p < .001), while the change in speed did not appear to be consistently related to a single factor. CONCLUSION: Handwriting difficulties are common in children with ADHD, and medication alone is not sufficient to resolve these challenges.

Motor skills of children newly diagnosed with Attention Deficit Hyperactivity Disorder prior to and following treatment with stimulant medication.

Motor difficulties are common in children with Attention Deficit Hyperactivity Disorder (ADHD). Although preliminary evidence has suggested that methylphenidate can improve the motor skills in children with ADHD and Developmental Coordination Disorder (DCD), the effect of stimulant medication on motor performance in children newly diagnosed with ADHD with or without motor impairment remains unclear. A cohort study of 49 medication-naïve children (39 male; mean age 8.4±1.3 years) with ADHD was conducted. Children were evaluated using the Movement Assessment Battery for Children and the developmental test of visual motor integration at diagnosis and again three months following daily treatment with a stimulant medication. Motor difficulties were highly present at baseline (73.5%) but resolved in a subset after treatment with stimulant medication, suggesting that their motor difficulties may be attributed in part to their attentional problems. Nevertheless, motor impairment persisted in 55.1% of the sample. The severity of the behavioural symptoms was significantly associated with balance skills in children without motor impairments (r(2)=0.30, p<0.01) and with visual motor integration skills in children with persisting motor difficulties (r(2)=0.27, p<0.01). Attentional difficulties negatively affect the motor skills of children with ADHD. Following the use of stimulant medication, an important subset continued to demonstrate motor difficulties. The improvement in behaviour was insufficient to resolve motor problems and these children should therefore be targeted for rehabilitation services.

Serotonergic contribution to boys' behavioral regulation.

OBJECTIVES: Animal and human adult studies reveal a contribution of serotonin to behavior regulation. Whether these findings apply to children is unclear. The present study investigated serotonergic functioning in boys with a history of behavior regulation difficulties through a double-blind, acute tryptophan supplementation procedure. METHOD: Participants were 23 boys (age 10 years) with a history of elevated physical aggression, recruited from a community sample. Eleven were given a chocolate milkshake supplemented with 500 mg tryptophan, and 12 received a chocolate milkshake without tryptophan. Boys engaged in a competitive reaction time game against a fictitious opponent, which assessed response to provocation, impulsivity, perspective taking, and sharing. Impulsivity was further assessed through a Go/No-Go paradigm. A computerized emotion recognition task and a staged instrumental help incident were also administered. RESULTS: Boys, regardless of group, responded similarly to high provocation by the fictitious opponent. However, boys in the tryptophan group adjusted their level of responding optimally as a function of the level of provocation, whereas boys in the control group significantly decreased their level of responding towards the end of the competition. Boys in the tryptophan group tended to show greater perspective taking, tended to better distinguish facial expressions of fear and happiness, and tended to provide greater instrumental help to the experimenter. CONCLUSIONS: The present study provides initial evidence for the feasibility of acute tryptophan supplementation in children and some effect of tryptophan supplementation on children's behaviors. Further studies are warranted to explore the potential impact of increased serotonergic functioning on boys' dominant and affiliative behaviors.

Handwriting capacity in children newly diagnosed with Attention Deficit Hyperactivity Disorder.

UNLABELLED: Preliminary evidence suggests that children with Attention Deficit Hyperactivity Disorder (ADHD) may exhibit handwriting difficulties. However, the exact nature of these difficulties and the extent to which they may relate to motor or behavioural difficulties remains unclear. The aim of this study was to describe handwriting capacity in children newly diagnosed with ADHD and identify predictors of performance. Forty medication-naïve children with ADHD (mean age 8.1 years) were evaluated with the Evaluation Tool of Children's Handwriting-Manuscript, the Movement Assessment Battery for Children (M-ABC), the Developmental Test of Visual Motor Integration (VMI) and the Conner Global Index. An important subset (85.0%) exhibited manual dexterity difficulties. Handwriting performance was extremely variable in terms of speed and legibility. VMI was the most important predictor of legibility. Upper extremity coordination, as measured by the M-ABC ball skills subtest, was also a good predictor of word legibility. CONCLUSION: Poor handwriting legibility and slow writing speed were common in children newly diagnosed with ADHD and were associated with motor abilities. Future studies are needed to determine whether interventions, including stimulant medications, can improve handwriting performance and related motor functioning.

Omega-3 fatty acid treatment of children with attention-deficit hyperactivity disorder: A randomized, double-blind, placebo-controlled study.

BACKGROUND: Although several clinical trials have evaluated the impact of n-3 polyunsaturated fatty acid (PUFA) on patients with attention-deficit hyperactivity disorder (ADHD), changes in plasma PUFA composition were not always assessed following n-3 supplementation. Furthermore, no reports are available on the efficacy of n-3 PUFA in Canadian youth with ADHD. OBJECTIVES: To determine fatty acid (FA) composition, and the efficacy and safety of n-3 PUFA supplementation on ADHD clinical symptoms in French Canadian primary school children. PATIENTS AND METHODS: The Strengths and Weaknesses in ADHD and Normal Behaviors (SWAN) and Conners' questionnaires were used to assess changes in ADHD symptoms in 37 children (only 26 children completed the study from zero to 16 weeks). They were divided into two groups (A and B), and participated in a 16-week, double-blind, one-way, crossover randomized study. In the first phase, group A received the n-3 PUFA supplement and group B received n-6 PUFA (sunflower oil) as a placebo. During the second phase, group B received the active n-3 PUFA supplement that was continued in group A. FA composition and lipid profile were assessed during the phases of the study. RESULTS: FA differences between groups were observed in the 26 patients. Supplementation with n-3 PUFA resulted in significant increases in eicosapentaenoic and docosahexaenoic acids in group A, while group B was enriched with alpha-linolenic, gamma-linolenic and homo-gamma-linolenic acids. The n-3 PUFA supplement was tolerated without any adverse effects. A statistically significant improvement in symptoms was noted based on the parent version of the Conners' questionnaire from baseline to the end of phase 1, and this amelioration continued from phases 1 to 2, although the latter changes from phases 1 and 2 were not statistically significant in any of the subscales except for the subscale measuring inattention in group B. The improvement was greater in patients from group A in phase 1 and in patients from group B in phase 2. A subgroup of eight patients (four in each group) displayed a statistically significant clinical improvement following the administration of the n-3 PUFA supplement, particularly for the inattention and global Diagnostic and Statistical Manual of Mental Disorders, Fourth edition, total Conners' subscales. CONCLUSIONS: A subgroup of children with ADHD who used n-3 PUFA supplements achieved and maintained symptom control. The data of the present study also supported n-3 PUFA safety and tolerability, but limited changes were noted in the FA profile in French Canadians with ADHD.