Young Children with Attention-Deficit/Hyperactivity Disorder and/or Disruptive Behavior Disorders Are More Frequently Prescribed Alpha Agonists Than Stimulants.

Objective: To examine medication prescribing patterns for preschool-aged children with diagnoses of attention-deficit/hyperactivity disorder (ADHD) and/or disruptive behavior disorder (DBD). Secondary objectives included determining if prescription patterns varied by gender, insurance type, or comorbid diagnosis of autism spectrum disorder (ASD). Methods: A retrospective, cross-sectional chart review was completed for children ages 2-5 years who were treated at an academic medical center between 2013 and 2016 with a diagnosis of ADHD and/or DBD. Data were analyzed by Fisher's exact and chi-square tests and Cochran-Armitage trend analysis. Results: Of the 966 children who met inclusion criteria, 343 (35.5%) were prescribed ADHD medications. For 2-, 3-, and 4-year olds, the most commonly prescribed medication was an alpha agonist (AA), while for 5-year olds, methylphenidate (MPH) was most commonly prescribed. With advancing age, an increasing number of children were prescribed a stimulant medication and a decreasing number of children were prescribed an AA (p < 0.001). Children were more often prescribed an MPH formulation (48.2%) compared with amphetamine-based stimulants (26.8%). Children without ASD were more likely to be prescribed a stimulant medication (72.1%) when compared with children with ASD (37.0%, p < 0.0001). Children with private insurance were more likely to be prescribed an extended-release stimulant medication when compared with Medicaid patients (34.3% vs. 17.2%, p = 0.004). Conclusion: Both stimulants and nonstimulants are being prescribed regularly in very young children, even before the age of four at an academic medical center. AAs were the most commonly prescribed medication for children 2, 3, and 4 years of age with diagnoses of ADHD, DBD, and ASD. Insurance type, comorbid diagnosis of ASD, and age of child were found to be significantly associated with prescribing a nonpreferred medication.

Effectiveness and Side Effect Profile of Stimulant Medication for the Treatment of Attention-Deficit/Hyperactivity Disorder in Youth with Epilepsy.

OBJECTIVES: This clinical case series examined the effectiveness and potential side effects associated with stimulant medication for the treatment of attention-deficit/hyperactivity disorder (ADHD) in 20 youth with epilepsy. METHODS: Response to stimulant medication was examined through symptom reduction on the Conners-Third Edition: Parent Rating Scale, Short Form [Conner 3-P(S)], which was administered to caregivers before initiation of treatment and following dosage titration to achieve therapeutic efficacy. Stimulant medication side effects were examined with the Side Effect Rating Scale before treatment and following dosage titration. Repeated measures mixed model approach was used to compare symptom reduction and side effects between the two time points. RESULTS: Repeated measures ANOVA revealed significant ADHD symptom reduction as measured by the Conner 3-P(S). Review of patient medical records and caregiver report did not reveal seizure exacerbation. Caregivers, in fact, reported fewer side effects following treatment for ADHD compared with baseline. CONCLUSION: These results contribute to growing evidence in support of the effectiveness of stimulant medication, without seizure exacerbation or medication side effects, for treatment of ADHD in youth with epilepsy.

Identification of ADHD in youth with epilepsy.

PURPOSE: To further characterize Attention-Deficit/Hyperactivity Disorder (ADHD) in a clinic-referred sample of youth with epilepsy. METHODS: Children and adolescents with epilepsy who were referred for comprehensive neuropsychological evaluation comprised the sample. Data were obtained via archival record review. Youth with epilepsy were grouped according to ADHD diagnosis (no ADHD, ADHD - Combined Type, and ADHD - Predominantly Inattentive Type) and compared for a number of neurocognitive variables, seizure-related variables, and parent and teacher completed behavior rating scale variables. Data was examined via analysis of variance and logistic regression models with post hoc pairwise comparisons, employing Tukey procedure where appropriate. RESULTS: Youth in this clinical case series (N = 204) demonstrated a high rate of ADHD diagnosis. ADHD - Combined Type was identified with slightly greater frequency than ADHD - Predominantly Inattentive Type. Age of seizure onset, seizure classification, and seizure frequency did not differ significantly between the groups. The groups also did not differ on most cognitive variables examined. Significant group differences were found for parent and teacher completed behavior rating scales assessing inattention, hyperactivity, and executive dysfunction. CONCLUSION: Screening for ADHD in youth with epilepsy is important as these symptoms can significantly interfere with rehabilitative efforts. Behavior rating scales may be the most efficient and cost effective way to identify ADHD in youth with epilepsy.

Not All Generic Concerta Is Created Equal: Comparison of OROS Versus Non-OROS for the Treatment of ADHD.

Treatment effectiveness between equivalent doses of non-OROS (osmotic controlled release oral delivery system) methylphenidate ER and OROS methylphenidate ER (brand name Concerta) was examined in a clinical case series of children and adolescents followed for treatment of attention-deficit/hyperactivity disorder (ADHD). The Conners-Third Edition: Parent Rating Scale was used to compare ADHD symptoms when patients were taking non-OROS versus OROS at follow-up visits. A repeated-measures mixed-model approach was used to compare treatment effectiveness. The entire sample (N = 14) demonstrated a reduction in the mean score on the Inattention Scale from clinically significant (T-score > 65) to not clinically significant (T-score < 65) when patients were changed from non-OROS to OROS at the same dosage (mean T-score reduction = 23, p < .0001). The reduction in mean T-score after changing from non-OROS to OROS at the same dosage is indicative of improvement in symptoms of ADHD. Results provide empirical support for US Food and Drug Administration concerns regarding the therapeutic equivalence of non-OROS versus OROS for the treatment of ADHD.

The health education for lupus study: a randomized controlled cognitive-behavioral intervention targeting psychosocial adjustment and quality of life in adolescent females with systemic lupus erythematosus.

INTRODUCTION: To examine in a randomize controlled feasibility clinical trial the efficacy of a cognitive-behavioral intervention designed to manage pain, enhance disease adjustment and adaptation and improve quality of life among female adolescents with systemic lupus erythematosus. METHODS: Female adolescents (n = 53) ranging in age from 12 to 18 years were randomly assigned to 1 of 3 groups including a cognitive-behavioral intervention, an education-only arm and a no-contact control group. Participants were assessed at baseline, postintervention and at 3- and 6-month intervals after completion of the intervention. RESULTS: No significant differences were revealed among the 3 treatment arms for any of the dependent measures at any of the assessment points. For the mediator variables, a posthoc secondary analysis did reveal increases in coping skills from baseline to postintervention among the participants in the cognitive-behavioral intervention group compared with both the no-contact control group and the education-only group. CONCLUSION: Although no differences were detected in the primary outcome, a possible effect on coping of female adolescents with systemic lupus erythematosus was detected in this feasibility study. Whether the impact of training in the area of coping was of sufficient magnitude to generalize to other areas of functioning, such as adjustment and adaptation, is unclear. Future phase III randomized trials will be needed to assess additional coping models and to evaluate the dose of training and its influence on pain management, adjustment and health-related quality of life.

Ameliorating attention problems in children with sickle cell disease: a pilot study of methylphenidate.

OBJECTIVE: This pilot study examined whether methylphenidate (MPH) was effective in enhancing cognitive performance and attention for children with sickle cell disease (SCD) with cerebrovascular complications who evidence attention problems. METHODS: In this multisite, pilot study, we evaluated 2 separate double-blind controlled clinical trials, including a laboratory trial of the short-term efficacy of MPH, with the second study a 3-week home/school crossover trial evaluating the efficacy of MPH. The laboratory trial included 14 participants between the age of 7 and 16 years. Assessments included measures of sustained attention, reaction time, executive functions, and verbal memory. The home/school trial included 20 participants. The outcome measures were parent and teacher ratings of attention. The first study compared MPH with placebo, while the second trial compared placebo, low-dose (LD) MPH, and moderate-dose MPH. RESULTS: In the laboratory trial, significant effects were revealed for measures of memory and inhibitory control. Parent and teacher reports from the home/school trial indicate that moderate-dose MPH produced superior improvement in attention relative to the placebo and LD MPH. CONCLUSIONS: Stimulant medication positively impacted select measures of memory and inhibitory control in some children with SCD. Attention, as rated by parent and teachers, was improved for a greater number of children and adolescents on higher doses of MPH relative to LD MPH and placebo. Stimulant medication may provide an effective intervention for some children with SCD and cerebrovascular complications who demonstrate attention problems.

The role of neuropsychological evaluation in pediatric sickle cell disease.

Neuropsychological impairment occurs in children and adolescents with sickle cell disease. While the neuropsychological sequelae associated with cerebrovascular disease in these children have been identified, a well-informed clinical approach to neuropsychological evaluation for these vulnerable children has not been delineated. Moreover, issues related to standard of care for children and adolescents with sickle cell disease and transition to adulthood remain understudied despite the relevance to long-term medical, psychosocial, and neuropsychological outcomes. We provide recommendations for an informed approach to neuropsychological evaluation of youth with sickle cell disease that is determined by pertinent illness-related factors, consideration of general developmental level and timing of evaluation (i.e., baseline vs follow-up evaluation), relationship to medical treatment, and transition to adulthood. Although the neuropsychological methods presented in this manuscript are specific to sickle cell disease, this empirically informed approach may serve as a model for other pediatric populations.

Radiographic predictors of neurocognitive functioning in pediatric Sickle Cell disease.

We compared magnetic resonance imaging (MRI), magnetic resonance angiography, and transcranial Doppler ultrasonography as predictors of specific neurocognitive functions in children with sickle cell disease. Participants were 27 children with sickle cell anemia (hemoglobin SS) who were participants in the Stroke Prevention Trial in Sickle Cell Anemia (STOP) and had no documented history of stroke. Children's MRIs were classified as normal or silent infarct, and their magnetic resonance angiograms were classified as normal or abnormal. The highest time-averaged mean flow velocity on transcranial Doppler ultrasonographic examination of the major cerebral arteries was analyzed. Age and hematocrit also were analyzed as predictor variables. The battery of neurocognitive tests included measures of intellectual functioning, academic achievement, attention, memory, visual-motor integration, and executive functions. MRI, magnetic resonance angiography, transcranial Doppler ultrasonography, age, and hematocrit were analyzed as predictors of participants' performance on the various measures of neurocognitive functioning. Age and hematocrit were robust predictors of a number of global and specific neurocognitive functions. When age and hematocrit were controlled, transcranial Doppler ultrasonography was a significantly unique predictor of verbal memory. We found an association between low hemoglobin and neurocognitive impairment. We also found that abnormalities on transcranial Doppler ultrasonography can herald subtle neurocognitive deficits. (J Child Neurol 2006;21:37-44).

Transcranial Doppler ultrasonography and executive dysfunction in children with sickle cell disease.

OBJECTIVE: To identify behavioral manifestations of executive dysfunction that are associated with cerebrovasculopathy, as measured by transcranial Doppler (TCD) ultrasonography, in children with sickle cell disease (HbSS). METHODS: Participants were 62 children and adolescents with HbSS disease who had no documented history of cerebrovascular accident. Children were classified according to the National Institutes of Health Stroke Prevention Trial in Sickle Cell Anemia (STOP) criteria (i.e., normal, conditional, and abnormal). RESULTS: Although children with abnormal TCD values were rated by their parents as exhibiting greater executive dysfunction in the areas of inhibitory control, problem-solving flexibility, and modulation of emotional responses compared with children in the conditional group, these differences were not clinically significant. In contrast, teachers rated children in the abnormal TCD group as having clinically significant executive dysfunction as manifested in their ability to solve problems in working memory, plan and organize, and self-monitor. CONCLUSIONS: Our findings lend preliminary support for the utility of teacher-completed screening instruments designed to assess everyday behaviors associated with executive dysfunction in children with HbSS disease, especially among those children at greatest risk for neurological impairment as identified by TCD ultrasonography.

Transcranial Doppler ultrasonography and neurocognitive functioning in children with sickle cell disease.

OBJECTIVE: We examined the relationship between cerebral blood flow velocity, measured by transcranial Doppler (TCD) ultrasonography, and neurocognitive functioning. METHODS: Participants were 60 children who had sickle cell disease (HbSS) and had no documented history of stroke. Children were classified according to Stroke Prevention Trial in Sickle Cell Anemia criteria (normal, conditional, and abnormal), and their performance was compared on measures of intellectual abilities, academic achievement, sustained attention/concentration, executive function, and parent and teacher ratings of executive function. RESULTS: Children with abnormal TCD values performed more poorly than children with conditional TCD values on measures of verbal intelligence and executive function. Children with conditional TCD values performed more poorly than children with normal TCD values on measures of sustained attention/concentration and executive function. TCD values also were a significant predictor of auditory working memory in exploratory analyses. CONCLUSIONS: Our findings support the hypothesis that neurocognitive functions subserved by the frontal systems (eg, sustained attention/concentration and executive function) seem to be the most useful indices of progressive cerebrovasculopathy in children with HbSS disease.