WHAT'S NEW IN ADHD
Practical Tips From New Research on ADHD
By Gabriel Kaplan, MD |
November 5, 2012
Dr Kaplan is Clinical Associate Professor of Psychiatry at the University of Medicine and Dentistry of New Jersey in Newark and Medical Director of Behavioral Health Services at the Bergen Regional Medical Center in Paramus, NJ. He reports that he is a consultant for Ogilvy CommonHealth.
ADHD and diet
All child and adolescent psychiatrists have interviewed at least 1 parent who strongly asserted that this or that type of food caused their offspring to become more acutely symptomatic, while eating other types of foods improved symptoms. The therapeutic and pathogenic theoretical roles of foods in ADHD, however, have fallen into disfavor since the 1980s, and most clinicians have tended to take parental reports regarding dietary effects with a certain degree of skepticism.
The results of 2 recent analyses may validate such previously discredited parental reports to some extent. Bloch and Qawasmi17 found that omega-3 fatty acid supplementation, particularly with higher doses of eicosapentaenoic acid, was modestly effective for treating ADHD. Nigg and colleagues18 studied the role of diet and food colors and found that restriction diets reduced ADHD symptoms and that an estimated 8% of children who have ADHD may have symptoms related to synthetic food colors.
Practical tip: An emerging body of evidence has concluded that certain artificial dyes used in food seem to increase hyperactivity and their elimination from the diet of children may improve behavior and attention, although the effect sizes of these approaches are much lower than those of stimulants (Figure 2). These data are intriguing but do not yet support routine dietary assessments.
On the other hand, clinicians should not dismiss unsolicited parental reports of food effects as invalid; explore these reports further and consider recommending a diet that excludes the posited offending agent. Furthermore, since fatty acids have a benign adverse-effect profile, they could be used to supplement/augment usual medications or they could be recommended in cases in which families are averse to prescription drugs but not opposed to over-the-counter options.
Recently published articles on the cardiovascular safety of ADHD agents
ADHD and driving
Obtaining the first driving license generally causes exhilaration in teenagers and anxiety in parents. For ADHD patients, the newly acquired independence that driving brings can also carry additional risks, because there is evidence that ADHD may impair motor vehicle operation. Stimulant medication, however, appears to improve driving skills in persons with ADHD.
Biederman and colleagues19 conducted a randomized, double-blind, 6-week, placebo-controlled, parallel-design study to determine the effect of lisdexamfetamine (LDX) on driving performance in a validated driving simulation paradigm. Sixty-one 18- to 26-year-old outpatients of both sexes with ADHD were randomized to receive LDX or placebo after a baseline driving simulation. They completed a second driving simulation 6 weeks after beginning the drug or placebo. LDX treatment was associated with significantly faster reaction times and a lower rate of simulated driving collisions.
In another study, Cox and colleagues20 investigated whether methylphenidate(Drug information on methylphenidate) delivered through a long-acting transdermal system (MTS) would reduce collision rates of young adult drivers with ADHD. Seventeen young adults completed this open-label, crossover design study in which drivers were randomly assigned either to no medication for 3 months and then MTS for 3 months or to the reverse sequence. In-car video monitoring of routine driving occurred during these 6 months. Participants who were receiving MTS had fewer video-recorded collisions and other problematic driving events.
Practical tip: Distracted driving has become a public health concern, eliciting comments from federal officials such as Secretary of Transportation Ray LaHood, who has called it “an epidemic on America’s roadways.” Psychiatrists have not routinely addressed the issue of driving with their ADHD patients. Given the compelling evidence, however, families who are considering medication for their adolescent should be made aware of these data because they could offer improved reassurance that the risk to bene-fit ratio for symptomatic driving-age youths favors the use of ADHD medication.
The overwhelming number of articles published about ADHD every year necessitates that clinicians rely on aggregators to highlight the most significant articles in their quest to improve the quality and options of care offered to patients. This article outlines the latest research on topics of high importance to the field. Nothing can replace, however, a direct examination of the data, so readers are encouraged to review the original reports for those topics they have found most interesting.
1. Kaplan G, Newcorn JH. Pharmacotherapy for child and adolescent attention-deficit hyperactivity disorder. Pediatr Clin North Am. 2011;58:99-120, xi.
2. Hodgkins P, Kahle J, Sikirica V, et al. The hidden costs of attention-deficit/hyperactivity disorder (ADHD): a focus on school and work in the United States. Presented at: 165th Annual Meeting of the American Psychiatric Association; May 5-9, 2012; Philadelphia. Abstract NR4-19.
3. Gould MS, Walsh BT, Munfakh JL, et al. Sudden death and use of stimulant medications in youths. Am J Psychiatry. 2009;166:992-1001.
4. Hammerness PG, Perrin JM, Shelley-Abrahamson R, Wilens TE. Cardiovascular risk of stimulant treatment in pediatric attention-deficit/hyperactivity disorder: update and clinical recommendations. J Am Acad Child Adolesc Psychiatry. 2011;50:978-990.
5. Schelleman H, Bilker WB, Strom BL, et al. Cardiovascular events and death in children exposed and unexposed to ADHD agents. Pediatrics. 2011;127:1102-1110.
6. Habel LA, Cooper WO, Sox CM, et al. ADHD medications and risk of serious cardiovascular events in young and middle-aged adults. JAMA. 2011;306:2673-2683.
7. Cooper WO, Habel LA, Sox CM, et al. ADHD drugs and serious cardiovascular events in children and young adults. N Engl J Med. 2011;365:1896-1904.
8. Olfson M, Huang C, Gerhard T, et al. Stimulants and cardiovascular events in youth with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2012;51:147-156.
9. Vitiello B, Elliott GR, Swanson JM, et al. Blood pressure and heart rate over 10 years in the multimodal treatment study of children with ADHD. Am J Psychiatry. 2012;169:167-177.
10. Comer JS, Olfson M, Mojtabai R. National trends in child and adolescent psychotropic polypharmacy in office-based practice, 1996-2007. J Am Acad Child Adolesc Psychiatry. 2010;49:1001-1010.
11. Stocks JD, K Taneja B, Baroldi P, L Findling R. A phase 2a randomized, parallel group, dose-ranging study of molindone in children with attention-deficit/hyperactivity disorder and persistent, serious conduct problems. J Child Adolesc Psychopharmacol. 2012;22:102-111.
12. Pliszka SR, Sikirica V, Dammerman R, et al. A comparison of rates and reasons for urgent care utilization among children with ADHD treated with atypical antipsychotics vs non-antipsychotics. Presented at: 165th Annual Meeting of the American Psychiatric Association; May 5-9, 2012; Philadelphia. Abstract NR4-12.
13. Ben Amor L. Antipsychotics in pediatric and adolescent patients: a review of comparative safety data. J Affect Disord. 2012;138(suppl):S22-S30.
14. Pappadopulos E, Rosato NS, Correll CU, et al. Experts’ recommendations for treating maladaptive aggression in youth. J Child Adolesc Psychopharmacol. 2011;21:505-515.
15. Kupfer DJ, Regier DA. The future of psychiat-ric diagnosis: updates on proposed diagnostic criteria. Presented at: 165th Annual Meeting of the American Psychiatric Association; May 5-9, 2012; Philadelphia.
16. American Psychiatric Association. DSM-5 Development: A 06 Attention Deficit/Hyperactivity Disorder. http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383#. Accessed September 26, 2012.
17. Bloch MH, Qawasmi A. Omega-3 fatty acid supplementation for the treatment of children with attention-deficit/hyperactivity disorder symptomatology: systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry. 2011;50:991-1000.
18. Nigg JT, Lewis K, Edinger T, Falk M. Meta-analysis of attention-deficit/hyperactivity disorder or attention-deficit/hyperactivity disorder symptoms, restriction diet, and synthetic food color additives. J Am Acad Child Adolesc Psychiatry. 2012;51:86-97.e8.
19. Biederman J, Fried R, Hammerness P, et al. The effects of lisdexamfetamine dimesylate on the driving performance of young adults with ADHD: a randomized, double-blind, placebo-controlled study using a validated driving simulator paradigm. J Psychiatr Res. 2012;46:484-491.
20. Cox DJ, Davis M, Mikami AY, et al. Long-acting methylphenidate reduces collision rates of young adult drivers with attention-deficit/hyperactivity disorder. J Clin Psychopharmacol. 2012;32:225-230.