Tine Houmann

Diet in the treatment of ADHD in children—A systematic review of the literature

Abstract Background: Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric conditions in childhood. Dietary changes have been suggested as a way of reducing ADHD symptoms. Aims: To provide an overview of the evidence available on dietary interventions in children with ADHD, a systematic review was carried out of all dietary intervention studies in children with ADHD. Methods: Relevant databases were searched in October 2011, with an update search in March 2013. The studies included describe diet interventions in children with ADHD or equivalent diagnoses measuring possible changes in core ADHD symptoms: inattention, hyperactivity and impulsivity. Results: A total of 52 studies were identified, some investigating whether ADHD symptoms can improve by avoiding certain food elements (20 studies), and some whether certain food elements may reduce ADHD symptoms (32 studies). Conclusion: Elimination diets and fish oil supplementation seem to be the most promising dietary interventions for a reduction in ADHD symptoms in children. However, the studies on both treatments have shortcomings, and more thorough investigations will be necessary to decide whether they are recommendable as part of ADHD treatment.

Can a general health surveillance between birth and 10 months identify children with mental disorder at 1½ year?

UNLABELLED Mental health surveillance in infancy was studied in an existing child health surveillance programme with child psychiatric disorder at 1(1/2) year as the outcome. METHODS Children considered of concern by community health nurses were cases in a case control study nested in the Copenhagen Child Cohort (CCC 2000). Outcome was mental health status at 1(1/2) year assessed by clinical and standardised strategies, including videotape recordings, parent interviews and the instruments: CBCL 1(1/2)-5, ITSCL, CHAT, Bayley Scales of Infant Development II, PC ERA and PIR-GAS. RESULTS The positive predictive value of concern in the first 10 months of living was 24% (CI 17.0-31.9), the negative predictive value was 85% (CI 77.9-89.6) and the sensitivity was 56% (CI 42.4-69.0). Concern about development was significantly associated with the child having a neuro-developmental disorder at 1(1/2) year, and concern about mother-child relationship was associated with emotional, behavioural, eating, and sleeping disturbances. CONCLUSIONS A general health surveillance program seems to have potentials to identify infants at risk for mental health problems provided standardised measures and specific training of the involved health professionals.Mental health surveillance in infancy was studied in an existing child health surveillance programme with child psychiatric disorder at 1½ year as the outcome. Methods Children considered of concern by community health nurses were cases in a case control study nested in the Copenhagen Child Cohort (CCC 2000). Outcome was mental health status at 1½ year assessed by clinical and standardised strategies, including videotape recordings, parent interviews and the instruments: CBCL 1½-5, ITSCL, CHAT, Bayley Scales of Infant Development II, PC ERA and PIR-GAS. Results The positive predictive value of concern in the first 10 months of living was 24% (CI 17.0–31.9), the negative predictive value was 85% (CI 77.9–89.6) and the sensitivity was 56% (CI 42.4–69.0). Concern about development was significantly associated with the child having a neuro-developmental disorder at 1½ year, and concern about mother–child relationship was associated with emotional, behavioural, eating, and sleeping disturbances. Conclusions A general health surveillance program seems to have potentials to identify infants at risk for mental health problems provided standardised measures and specific training of the involved health professionals.

Individualization of treatments with drugs metabolized by CES1: combining genetics and metabolomics

CES1 is involved in the hydrolysis of ester group-containing xenobiotic and endobiotic compounds including several essential and commonly used drugs. The individual variation in the efficacy and tolerability of many drugs metabolized by CES1 is considerable. Hence, there is a large interest in individualizing the treatment with these drugs. The present review addresses the issue of individualized treatment with drugs metabolized by CES1. It describes the composition of the gene encoding CES1, reports variants of this gene with focus upon those with a potential effect on drug metabolism and provides an overview of the protein structure of this enzyme bringing notice to mechanisms involved in the regulation of enzyme activity. Subsequently, the review highlights drugs metabolized by CES1 and argues that individual differences in the pharmacokinetics of these drugs play an important role in determining drug response and tolerability suggesting prospects for individualized drug therapies. Our review also discusses endogenous substrates of CES1 and assesses the potential of using metabolomic profiling of blood to identify proxies for the hepatic activity of CES1 that predict the rate of drug metabolism. Finally, the combination of genetics and metabolomics to obtain an accurate prediction of the individual response to CES1-dependent drugs is discussed.

Prescription rates of ADHD medication in the Scandinavian countries and their national guidelines.

A recent study reported substantial differences concerning the use of medication for Attention-Defi cit/ Hyperactivity (ADHD) across the Nordic countries (1). More surprisingly, the variation across the three rather “ homogeneous ” Scandinavian countries was substantial, with a prevalence rate of ADHD medication (stimulants or atomoxetine) of 2.52 (Sweden), 4.73 (Norway) and 2.41 (Denmark) per 1000 inhabitants in all age groups. This is unexpected, given that the social structures are regarded as comparable in those three countries. In search of relevant causes for the variation, it seemed appropriate to turn to the guidelines for diagnosis and treatment of ADHD published in the three different Scandinavian countries (2–4). Although we are aware of the fact that working groups behind these guidelines in each country consisted of specialists from different professions, and that guidelines were developed with a view to reaching different target populations, we believe that it is important to point out that basic recommendations with respect to indication, dosage and follow-up of medication were divergent in the three guidelines. Even though the guidelines agree that clinical specialists of psychiatry and child-and adolescent psychiatry, paediatrics and neurology are authorized to initiate and prescribe medication, recommendations on laboratory tests before the prescription vary to some extent. Also, rating of ADHD symptoms before start of medication has only been recommended in the Swedish (SNAP IV) and Danish guidelines (ADHD-RS). Guidelines in all three countries favour methylphenidate as fi rst-line medication, whereas the guidelines are not congruent, with respect to which drug should be used as second-line treatment (atomoxetine or dexamphetamine). The three countries agree largely concerning their recommendation for dosage of medication; however, the Swedish guidelines do not give details for titration of medication in children, only in adults. Given the wide distribution of ADHD medication in different institutional settings, it would be appropriate to include recommendation for a max dosage per kilogram in children and adolescents for the specifi c medications in these documents. All three guidelines mention patients ’ follow-up as an important part of treatment; however, instructions concerning timelines and paraclinical measurements differ in detail. Based on these differences between the three Scandinavian countries with respect to their guidelines for medical treatment of ADHD, we would like to suggest that groups developing national guidelines should strive to include participants from neighbour countries in this process in the future. If, for practical reasons, it should be diffi cult to include participants from the other Scandinavian countries in the working group, we would recommend that drafts for guidelines from one country should be sent to national professional societies (for psychiatry or child and adolescent psychiatry) before publication, for hearing by the experts from the other countries to increase the similarities in the national guidelines. The aim is to harmonize recommendations