Alison Poulton

Slowing of growth in height and weight on stimulants: A characteristic pattern

Objective:  The aims of the present study were to describe the growth pattern of children starting stimulant medication and to analyse the changes over time in height, weight and height velocity in a cohort of treated patients.

Growth on stimulant medication; clarifying the confusion: a review

Aims: To get an overview of the studies of growth in height in children with attention deficit hyperactivity disorder (ADHD) treated with stimulant medication, to establish the consistencies and to try to resolve the discrepancies. Methods: Twenty nine studies were reviewed following a Medline search: 22 related to children, six to late adolescents or adults, and one to children and adults. Results:Children: Eleven studies gave results consistent with height attenuation on stimulant medication: eight were longitudinal, one was cross-sectional, and two showed growth rebound on ceasing medication. Studies with negative findings were inadequately powered (n = 3), lacked controls or statistical analysis (n = 3), measured height velocity without reference to treatment duration (n = 2), or used inappropriate growth parameters (n = 1), controls (n = 1), or normative data (n = 1). Late adolescents/adults treated with stimulant medication in childhood: Two studies associated childhood gastrointestinal side effects with attenuated late adolescent or adult height; all six cross-sectional studies had negative findings. The methodologies varied widely but there was some consistency in the degree of attenuation shown in studies with positive findings. The most sensitive methods analysed the changes in z-scores (standard deviation scores) or calculated the height deficits from paired measurements taken before and after an initial period of treatment with stimulant medication. The height deficit amounted to approximately 1 cm/year during the first 1–3 years of treatment. Conclusions: Further research is needed into the causal mechanisms, the rate of physical maturation, and the long term implications for final stature.

Expectation of life and unexpected death in open spina bifida: a 40‐year complete, non‐selective, longitudinal cohort study

Aim  The aim of our study was to investigate survival and causes of death in a complete cohort of open spina bifida at the mean age of 40 years.

Growth and pubertal development of adolescent boys on stimulant medication for attention deficit hyperactivity disorder

Objective: To investigate the growth and pubertal attainment of boys with attention deficit hyperactivity disorder (ADHD) on stimulant medication.

Comparison of maternal abdominal subcutaneous fat thickness and body mass index as markers for pregnancy outcomes: A stratified cohort study.

Obesity in pregnancy is associated with a number of adverse outcomes. The effects of central versus general obesity in pregnancy have not been well established.

Open spina bifida: birth findings predict long-term outcome

Objectives To investigate if lifestyle in spina bifida at age 40±3 years, relates to neurological deficit in infancy or cerebrospinal fluid shunt history. Design Prospective cohort study with 100% ascertainment. Setting Community. Participants 117 consecutive cases of open spina bifida whose backs were closed non-selectively at birth. In 2007, all 46 (39%) survivors and/or carers were surveyed by postal questionnaires and telephone interviews. Results Of the 38 children with absent sensation only below the knee (sensory level below L3), 23 (61%) survived of whom 14 (61%) were community walkers and only 5 (22%) needed daily care. But in 42 babies with absent sensation up to the umbilicus (sensory level above T11) only seven (17%) survived, none could walk and five (71%) needed daily care. Survivors with no shunt revisions were more likely to walk, live independently and drive a car. Conclusion Mobility and the need for care at 40 can be predicted from the neurological deficit.

Weight loss on stimulant medication: how does it affect body composition and bone metabolism? – A prospective longitudinal study

ObjectiveChildren treated with stimulant medication for attention deficit hyperactivity disorder (ADHD) often lose weight. It is important to understand the implications of this during growth. This prospective study was designed to quantify the changes in body composition and markers of bone metabolism on starting treatment.Methods34 children (29 boys) aged 4.7 to 9.1 years newly diagnosed with ADHD were treated with dexamphetamine or methylphenidate, titrating the dose to optimise the therapeutic response. Medication was continued for as long as clinically indicated. Body composition and bone density (dual-energy X-ray absorptiometry) were measured at baseline, 6 months and 3 years; changes were analysed in Z-scores based on data from 241 healthy, local children. Markers of bone turnover were measured at baseline, 3 months and 3 years.ResultsFat loss of 1.4±0.96kg (total fat 5.7±3.6 to 4.3±3.1kg, p<0.001) occurred in the first 6 months. There were significant reductions over 3 years in the sex and height corrected Z-scores for lean tissue, bone mineral content, bone mineral density and ratio of central to total fat (−0.84±0.86, p=0.003; -0.55±0.31, p<0.0001; -0.41±0.28, p<0.0001 and −0.55±0.62, p=0.006 respectively). Propeptide of type I collagen indicated a significant reduction in bone turnover after 3 months (564±202 to 458±96ng/ml, p=0.019), which was fully recovered after 3 years (619±276ng/ml).ConclusionsStimulant medication was associated with early fat loss and reduced bone turnover. Lean tissue including bone increased more slowly over 3 years of continuous treatment than would be expected for growth in height. There was long-term improvement in the proportion of central fat for height. This study shows that relatively minor reductions in weight on stimulant medication can be associated with long-term changes in body composition. Further study is required to determine the effects of these changes on adult health.

Long-term outcomes of stimulant medication in attention-deficit hyperactivity disorder

The rate of prescribing of stimulant medication for the treatment of attention-deficit hyperactivity disorder (ADHD) has been progressively increasing in countries such as the USA and Australia. In the short term, stimulant medication is effective in reducing the symptoms of ADHD and appears well tolerated with relatively minor side effects. In the long term, much of the benefit of stimulant medication disappears after medication is ceased. Studies have demonstrated only marginal improvements in adult outcomes following a period of treatment in childhood. This may be owing to the beneficial effects being masked by the variability of the condition, the developmental changes in symptomatology that happen with maturation and the substantial influence of social and environmental factors. Stimulant medication may give some protection against later substance abuse. Stimulant medication may slightly elevate the blood pressure and possibly increase susceptibility to seizures and to tics and Tourette syndrome. Starting treatment with stimulant medication is usually associated with weight loss and a transient slowing of the height velocity, although it is believed that most children catch up during puberty. No studies were found that listed strokes or heart attacks as potential or actual complications, although one individual from a group of normal controls died suddenly of cardiac arrest in adolescence. It would appear that the medical complications associated with amphetamine addiction are not relevant to the therapeutic use of stimulant medication in the treatment of ADHD, although there is limited information on extended periods of treatment lasting 10 years or more.

Growth and sexual maturation in children and adolescents with attention deficit hyperactivity disorder.

Purpose of review Growth and maturation in children and adolescents with attention deficit hyperactivity disorder has been the subject of controversy for many years. The purpose of this review is to describe the course of current opinion, summarize findings that have been supported by scientific evidence and show why one widely disseminated opinion is unfounded. Recent findings Recent studies have shown reductions in expected growth in height and weight in children starting treatment with stimulant medication. With prolonged treatment of 2–3 years, growth velocities show a trend towards normalization. There is evidence from recently published data that the effect of stimulant medication on growth is closely linked to its therapeutic effect – an interpretation which has not previously been reported. Normal growth velocities have been demonstrated in untreated children with attention deficit hyperactivity disorder. Summary Recent findings that children with attention deficit hyperactivity disorder treated with stimulant medication grow more slowly than untreated children confirm the results of the early studies of 1972–1973. This should now focus research towards the areas that require further investigation, such as establishing the mechanism of the stimulant-associated growth attenuation, and defining in more detail the effects of stimulant medication on growth and maturation in children of different ages.

Neurological level at birth predicts survival to the mid-40s and urological deaths in open spina bifida: a complete prospective cohort study

To conduct a 50‐year complete, community‐based, prospective cohort study to investigate long‐term survival, causes of death, and influence of level of the lesion in treated open spina bifida.