Tobias Banaschewski

European clinical guidelines for hyperkinetic disorder -- first upgrade.

AbstractBackgroundThe validitynof clinical guidelines changesnover time, because new evidencebasednknowledge and experiencendevelop.ObjectiveHence, the Europeannclinical guidelines on hyperkineticndisorder from 1998 had tonbe evaluated and modified.MethodDiscussions at the European Networknfor Hyperkinetic Disordersn(EUNETHYDIS) and iterative critiquenof each clinical analysis.nGuided by evidence-based informationnand based on evaluationn(rather than metaanalysis) of thenscientific evidence a group of childnpsychiatrists and psychologistsnfrom several European countriesnupdated the guidelines of 1998.nWhen reliable information is lackingnthe group gives a clinical consensusnwhen it could be foundnamong themselves.ResultsThengroup presents here a set of recommendationsnfor the conceptualisationnand management of hyperkineticndisorder and attentionndeficit/hyperactivity disordern(ADHD).ConclusionA generalnscheme for practice in Europencould be provided, on behalf of thenEuropean Society for Child andnAdolescent Psychiatry (ESCAP).

Long-acting medications for the hyperkinetic disorders : A systematic review and European treatment guideline

A systematic review of published and unpublished data on the use of long-acting medications in ADHD and hyperkinetic disorder is reported, giving effect sizes and numbers-to-treat for extended-release stimulant preparations and atomoxetine (ATX). A panel of experts from several European countries used the review to make recommendations about the use of these drugs in practice, and conclusions are reported: (1) Long-acting preparations should be available and used; (2) They should not replace short-acting drugs (which will be the initial treatment for many children for reasons of cost and flexibility of dosing). Individual clinical choice is needed. (3) Both ATX and extended-release preparations of stimulants should be available. The choice will depend upon the circumstances, and detailed recommendations are made.

European guidelines on managing adverse effects of medication for ADHD

The safety of ADHD medications is not fully known. Concerns have arisen about both a lack of contemporary-standard information about medications first licensed several decades ago, and signals of possible harm arising from more recently developed medications. These relate to both relatively minor adverse effects and extremely serious issues such as sudden cardiac death and suicidality. A guidelines group of the European Network for Hyperkinetic Disorders (EUNETHYDIS) has therefore reviewed the literature, recruited renowned clinical subspecialists and consulted as a group to examine these concerns. Some of the effects examined appeared to be minimal in impact or difficult to distinguish from risk to untreated populations. However, several areas require further study to allow a more precise understanding of these risks.

Association of ADHD and conduct disorder – brain electrical evidence for the existence of a distinct subtype

BACKGROUNDnTo evaluate the impact of psychopathological comorbidity with oppositional defiant/conduct disorder (ODD/CD) on brain electrical correlates in children with attention deficit hyperactivity disorder (ADHD) and to study the pathophysiological background of comorbidity of ADHD+ODD/CD.nnnMETHODnEvent-related potentials (ERPs) were recorded during a cued continuous performance test (CPT-A-X) in children (aged 8 to 14 years) with ICD-10 diagnoses of either hyperkinetic disorder (HD; n = 15), hyperkinetic conduct disorder (HCD; n = 16), or ODD/CD (n = 15) and normal children (n = 18). HD/HCD diagnoses in all children were fully concordant with the DSM-IV diagnosis of ADHD-combined type. ERP-microstates, i.e., time segments with stable brain electrical map topography were identified by adaptive segmentation. Their characteristic parameters and behavioral measures were further analyzed.nnnRESULTSnChildren with HD but not comorbid children showed slower and more variable reaction times compared to control children. Children with HD and ODD/CD-only but not comorbid children displayed reduced P3a amplitudes to cues and certain distractors (distractor-X) linked to attentional orienting. Correspondingly, global field power of the cue-CNV microstate related to anticipation and preparation was reduced in HD but not in HCD. Topographical alterations of the HD occurred already in the cue-P2/N2 microstate. In sum, the comorbid group was less deviant than both the HD-group and the ODD/CD-group.nnnCONCLUSIONSnThe findings suggest that HD children (ADHD-combined type without ODD/CD) suffer from a more general deficit (e.g., suboptimal energetical state regulation) including deficits of attentional orienting and response preparation than just a responseinhibitory deficit, backing the hypothesis of an involvement of a dysregulation of the central noradrenergic networks. The results contradict the hypothesis that ADHD+ODD/CD represents an additive co-occurrence of ADHD and ODD/CD and strongly suggest that it represents a separate pathological entity as considered in the ICD-10 classification system, which differs from both HD and ODD/CD-only.

Validation of the parent and teacher SDQ in a clinical sample.

Abstract.Objectives:This study examines whether the German translation of the Strengths and Difficulties Questionnaire (SDQ) is a reliable and valid screening instrument and whether it is as effective a tool for clinical diagnostics and scientific applications as the CBCL/TRF.Methods:We examined 543 children and adolescents (147 girls and 396 boys) with ages ranging from 5 to 17 years and correlated the results of the parent and teacher SDQ as well as the CBCL/TRF with clinical diagnoses. Furthermore, the adequacy of the scale structure of the SDQ was tested using confirmatory and exploratory factor analyses.Results:It was demonstrated that the scales of the parent and teacher versions were sufficiently homogeneous (0.72–0.83). Correlations between SDQ scales and corresponding CBCL/TRF scales showed a high degree of congruence, while an exact replication of the original SDQ scale structure could also be achieved. Parent and teacher versions of both questionnaires presented with good validity, not only with regard to the discrimination between child psychiatric patients and a representative community sample, but also in the identification of different categories of disorders within the clinical sample.Conclusion:The parent and teacher SDQs proved to be valid and helpful questionnaires for use in the framework of a multi-dimensional behavioural assessment, and appear to be well suited for screening purposes, longitudinal monitoring of therapeutic effects, and scientific research purposes.

Autism symptoms in Attention-Deficit/Hyperactivity Disorder: A Familial trait which Correlates with Conduct, Oppositional Defiant, Language and Motor Disorders

It is hypothesised that autism symptoms are present in Attention-Deficit/Hyperactivity Disorder (ADHD), are familial and index subtypes of ADHD. Autism symptoms were compared in 821 ADHD probands, 1050 siblings and 149 controls. Shared familiality of autism symptoms and ADHD was calculated using DeFries-Fulker analysis. Autism symptoms were higher in probands than siblings or controls, and higher in male siblings than male controls. Autism symptoms were familial, partly shared with familiality of ADHD in males. Latent class analysis using SCQ-score yielded five classes; Class 1(31%) had few autism symptoms and low comorbidity; Classes 2–4 were intermediate; Class 5(7%) had high autism symptoms and comorbidity. Thus autism symptoms in ADHD represent a familial trait associated with increased neurodevelopmental and oppositional/conduct disorders.

Reaction time performance in ADHD : improvement under fast-incentive condition and familial effects

BACKGROUNDnReaction time (RT) variability is one of the strongest findings to emerge in cognitive-experimental research of attention deficit hyperactivity disorder (ADHD). We set out to confirm the association between ADHD and slow and variable RTs and investigate the degree to which RT performance improves under fast event rate and incentives. Using a group familial correlation approach, we tested the hypothesis that there are shared familial effects on RT performance and ADHD.nnnMETHODnA total of 144 ADHD combined-type probands, 125 siblings of the ADHD probands and 60 control participants, ages 6-18, performed a four-choice RT task with baseline and fast-incentive conditions.nnnRESULTSnADHD was associated with slow and variable RTs, and with greater improvement in speed and RT variability from baseline to fast-incentive condition. RT performance showed shared familial influences with ADHD. Under the assumption that the familial effects represent genetic influences, the proportion of the phenotypic correlation due to shared familial influences was estimated as 60-70%.nnnCONCLUSIONSnThe data are inconsistent with models that consider RT variability as reflecting a stable cognitive deficit in ADHD, but instead emphasize the extent to which energetic or motivational factors can have a greater effect on RT performance in ADHD. The findings support the role of RT variability as an endophenotype mediating the link between genes and ADHD.

Premonitory sensory phenomena and suppressibility of tics in Tourette syndrome: developmental aspects in children and adolescents

Although premonitory sensory phenomena (PSP) and suppressibility of tics (SPT) are important in Tourette syndrome not only when behavioural therapeutic approaches in children are considered, there is a lack of developmental information on these phenomena. Therefore, a cross-sectional survey of these factors in children and adolescents was carried out. Rates of PSP and SPT were gathered using a questionnaire for the assessment of Tourette syndrome. The 254 outpatients (212 males, 42 females) with Tourette syndrome investigated had an age range of 8 to 19 years, normal intelligence, and diagnosis according to DSM-IV-TR/ICD-10. To test for developmental effects, the total group was stratified into three age groups (8 to 10, 11 to 14, and 15 to 19 years). Data were statistically evaluated using chi2 tests. Of the 254 participants, 37% reported PSP, while 64% were able to suppress their tics. Only a subgroup of 119 patients gave unequivocal answers to both questions and only 60% of these experienced both PSP and SPT. Statistically significant stepwise increases were found at two different age levels. One was around 10 years (PSP Yes or No and SPT), the other around age 14 (PSP Yes). There was no influence of tic duration and age at tic onset on PSP/SPT. The reported data suggest that PSP is experienced rarely in younger children with Tourette syndrome and is not a necessary prerequisite for SPT. Increasing PSP with age merely seems to reflect cognitive development rather than intrinsic aspects of Tourette syndrome. In children under 10 years of age, SPT might require more awareness of tics than in older age groups. Developmental aspects of PSP and SPT should be taken into consideration when studies of cognitive behavioural treatment for children and adolescents with Tourette syndrome are planned.

Action Monitoring in Boys With Attention-Deficit/Hyperactivity Disorder, Their Nonaffected Siblings, and Normal Control Subjects: Evidence for an Endophenotype

BACKGROUNDnAttention-deficit/hyperactivity disorder (ADHD) is a very common and highly heritable child psychiatric disorder associated with dysfunctions in fronto-striatal networks that control attention and response organization. The aim of this study was to investigate whether features of action monitoring related to dopaminergic functions represent endophenotypes that are brain functions on the pathway from genes and environmental risk factors to behavior.nnnMETHODSnAction monitoring and error processing as indicated by behavioral and electrophysiological parameters during a flanker task were examined in boys with ADHD combined type according to DSM-IV (n = 68), their nonaffected siblings (n = 18), and healthy control subjects with no known family history of ADHD (n = 22).nnnRESULTSnBoys with ADHD displayed slower and more variable reaction-times. Error negativity (Ne) was smaller in boys with ADHD compared with healthy control subjects, whereas nonaffected siblings displayed intermediate amplitudes following a linear model predicted by genetic concordance. The three groups did not differ on error positivity (Pe). The N2 amplitude enhancement due to conflict (incongruent flankers) was reduced in the ADHD group. Nonaffected siblings also displayed intermediate N2 enhancement.nnnCONCLUSIONSnConverging evidence from behavioral and event-related potential findings suggests that action monitoring and initial error processing, both related to dopaminergically modulated functions of anterior cingulate cortex, might be an endophenotype related to ADHD.

Non-stimulant medications in the treatment of ADHD.

AbstractBackgroundStimulantsnare the first–line medicationnin the psychopharmacologicalntreatment of attention–deficit hyperactivity disorder (ADHD). However,n10 to 30% of all children andnadults with ADHD either do not respondnto or do not tolerate treatmentnwith stimulants.ObjectiveTondescribe alternative treatment approachesnwith various non–stimulantnagents, especially atomoxetine.MethodGeneral review of empiricallynbased literature concerningnefficacy and safety of the substances.ResultsA large and still increasingnbody of data supports thenusefulness of atomoxetine, a oncendaily dosing, and new selectivennoradrenalin reuptake inhibitor,nwith few side effects. Atomoxetinenhas been licensed in the US for usenin ADHD across the lifespan, and isncurrently under consideration innEurope. Other non–stimulant substances,nsuch as tricyclic antidepressantsn(TCAs) and alpha–2–adrenergic agonists, which are usednto treat ADHD, are also reviewed.nTCAs have been well studied andnshown to be efficacious in thentreatment of ADHD, but are limitednby side effects. The number ofnstudies documenting the efficacy ofnalpha–2–adrenergic agonists is stillnlimited. Some experimental studiesnsupport a potential role of cholinergicndrugs such as acetylcholinesteraseninhibitors (tacrine,ndonepezil) as well as novel nicotinicnanalogues (ABT–418).ConclusionNon–stimulant agents havenbeen shown to be effective in treatmentnof ADHD. Especially, atomoxetinenseems promising and newlinendrugs are in development.