Valerie Arnold

Summary of the practice parameters for the assessment and treatment of children, adolescents, and adults with ADHD

This summary of the practice parameters describes the assessment, differential diagnosis, and treatment of children, adolescents, and adults who present with symptoms of attention-deficit/hyperactivity disorder. The rationales for specific recommendations are based on a review of the scientific literature and clinical consensus which is contained in the complete document. Assessment includes clinical interviews with the child and parents and standardized rating scales from parent and teachers. Testing of intelligence and academic achievement is usually required. Comorbidity is common. The cornerstones of treatment are support and education of parents, appropriate school placement, and psychopharmacology. The primary medications are psychostimulants, but antidepressants and alpha-adrenergic agonists are used in special circumstances. Other treatments such as behavior modification, school consultation, family therapy, and group therapy address remaining symptoms.

A 9-Week, Randomized, Double-Blind, Placebo-Controlled, Parallel-Group, Dose-Finding Study to Evaluate the Efficacy and Safety of Modafinil as Treatment for Adults With ADHD

Objective: This study evaluated the efficacy and tolerability of modafinil at a range of doses, versus placebo, in alleviating symptoms of ADHD in adults. Method: Adult patients with ADHD were randomized in 1:1:1:1:1 fashion to double-blind treatment with modafinil 255, 340, 425, or 510 mg daily or placebo for 9 weeks. The primary efficacy outcome was the change from baseline at final visit in the Adult ADHD Investigator Symptom Rating Scale (AISRS) total score. Results: A total of 338 patients were enrolled, of whom 330 received at least 1 dose of study medication (modafinil or placebo). No statistically significant difference in the AISRS total score was observed at final visit between any modafinil group and placebo; however, some observations among patients who completed the trial may warrant further investigation. Conclusion: Modafinil was reasonably tolerated but did not demonstrate a benefit on ADHD symptoms in adults.

Summary of the practice parameters for the assessment and treatment of children and adolescents with substance use disorders

This summary describes the assessment and treatment of children and adolescents with substance use disorders and is based on scientific evidence regarding diagnosis and effective treatment as well as on the current state of clinical practice. Given the paucity of research on the treatment of substance use disorders in children and adolescents, many of the recommendations are drawn from the adult literature and current clinical practice. This summary considers risk factors for substance use and related problems, normative use of substances by adolescents, the comorbidity of substance use disorders with other psychiatric disorders, and treatment settings and modalities.

The Effects of Lisdexamfetamine Dimesylate on Emotional Lability in Children 6 to 12 Years of Age With ADHD in a Double-Blind Placebo-Controlled Trial:

Objective: To evaluate the effect of lisdexamfetamine dimesylate (LDX) on emotional lability (EL) in children with ADHD. Method: Post hoc analyses of a placebo-controlled trial of LDX-stratified children (aged 6-12 years) with ADHD to prominent and not prominent EL at baseline (score >3 or ≤3, respectively, on Conners’ Parent Rating Scale [CPRS] items of anger, loss of temper, and irritability). Efficacy was assessed by change in CPRS EL scores and ADHD Rating Scale-IV (ADHD-RS-IV) total and subscale scores. Safety measures included treatment-emergent adverse events (TEAEs). Results: LDX showed improvement versus placebo (p < .0005) for EL item least squares (LS) mean change scores at endpoint and throughout the day. At baseline, 138 and 73 participants randomized to LDX treatment and having baseline and endpoint CPRS scores were categorized with CPRS-derived prominent and not prominent baseline EL, respectively; 41 and 31 participants randomized to placebo were categorized with CPRS-derived prominent and not prominent baseline EL, respectively. ADHD-RS-IV total and subscale scores decreased with LDX regardless of baseline EL severity. TEAEs included decreased appetite, insomnia, upper abdominal pain, headache, and irritability. Conclusion: EL and ADHD symptoms improved with LDX regardless of baseline EL symptom severity. LDX demonstrated a safety profile consistent with long-acting psychostimulant use.

Redundant clothing: A readily observable marker for schizophrenia in the psychiatric emergency room population☆

Most mental health workers have seen bizarrely dressed patients who wear multiple pieces of some item of clothing. Since many of these patients carried a schizophrenic diagnosis, we devised a study to test whether redundant clothing is a reliable indicator of schizophrenia. Of 25 patients who presented at the city psychiatric emergency room wearing redundant clothes, 18 received schizophrenic diagnoses. A Chi square analysis comparing proportions attained significance at the P < .0001 level. Although not a particularly sensitive measure, wearing redundant clothes appears to be a readily observable behavior associated with schizophrenia in the psychiatric emergency room.

Summary of the practice parameters for the assessment and treatment of children and adolescents with obsessive-compulsive disorder

This summary provides an overview of the assessment, differential diagnosis, and treatment recommendations contained in the Practice Parameters for the Assessment and Treatment of Children and Adolescents With Obsessive-Compulsive Disorder. OCD is a disorder of heterogeneous origin characterized by intrusive thoughts or compulsive urges or behaviors that are distressing, time-consuming, or functionally impairing. In children and adolescents, the disorder often is accompanied by a wide range of comorbidity. Two modalities have been systematically assessed and empirically shown to ameliorate the core symptoms of OCD: cognitive-behavioral therapy (primarily exposure/response prevention) and serotonin reuptake inhibitor medication. Additional individual and family psychotherapeutic, pharmacological, and educational interventions often are necessary.

Summary of the Practice Parameters for the Assessment and Treatment of Children and Adolescents with Language and Learning Disorders

This summary provides an overview of the recommendations contained in the Practice Parameters for the Assessment and Treatment of Children and Adolescents with Language and Learning Disorders. These disorders are among the most common developmental disorders. The diagnosis of language and learning disorders requires a discrepancy, based on age and intelligence, between potential and achievement. The clinician collaborates with parents and school personnel to clarify the diagnosis, implement appropriate treatment and remediation, and monitor progress. The clinician also is instrumental in identifying and treating comorbid conditions. Long-term prognosis depends on the type and severity of the language or learning disorder, the availability of remediation, and the presence of a supportive family and school environment.

ADHD Symptom Rebound and Emotional Lability With Lisdexamfetamine Dimesylate in Children Aged 6 to 12 Years

Objective: To describe symptom rebound in children with ADHD treated with lisdexamfetamine dimesylate (LDX) or placebo. Method: During a 4-week, randomized, double-blind, placebo-controlled trial of LDX, parents/caregivers completed the Conners’ Parent Rating Scale–Revised: Short Form symptom rating scale throughout the day. Response, rebound, and emotional lability (EL) were assessed post hoc based on predefined criteria. Results: Most participants given LDX (n = 207) were responders throughout the day (50.7%-55.6%) versus placebo (n = 72; 11.1%-22.2%). A total of seven (3.4%) LDX participants showed rebound in the afternoon and/or evening versus seven (9.7%) with placebo. In both groups, most incidences of rebound occurred in the evening. EL (mean) was higher in LDX rebounders and nonresponders (range = 4.2-9.0) versus LDX responders (range = 1.3-1.6) and versus placebo rebounders (range = 0.7-1.9). Conclusion: ADHD symptom rebound occurred in few participants (3.3%) given LDX (accompanied by clinically significant EL). Overall, more participants given LDX versus placebo responded throughout the day.

Aiming for remission in adults with attention-deficit/hyperactivity disorder: The primary care goal

Abstract Attention-deficit/hyperactivity disorder (ADHD) is often undiagnosed and undertreated in adults, resulting in wide-ranging problems and functional deficits in patients’ lives. In addition, psychiatric comorbidities unrelated to symptom severity may be present. However, effective treatment that can alleviate symptoms and bring about meaningful improvements in functionality is available. Primary care providers can play a crucial role in recognizing and diagnosing ADHD, initiating and monitoring treatment, and obtaining consultations or arranging referrals when necessary, all with the goal of achieving and maintaining remission. Fulfillment of this role requires a practical understanding of the diverse clinical manifestations of ADHD in patients stratified by age and sex, and familiarity with current treatment guidelines. Although there is no absolute consensus on the criteria by which remission is defined, treatment response may be guided by objective ratings of global symptom severity and patients’ self-reports of changes in their ability to cope with routine daily tasks, academic and vocational responsibilities, and social relationships. Although there has been much research into the genetic and neurophysiologic basis of ADHD, it is more important for primary care providers to appreciate that ADHD is a chronic condition requiring lifelong follow-up and that clinical presentation and response to treatment can vary widely among patients and over time in the same patients. Such variability makes the management of ADHD challenging, but the opportunity to bring about dramatic improvement in patients’ lives makes it imperative for primary care providers to be competent in this area. This review provides primary care clinicians with a practical definition of remission in adults with ADHD, to emphasize that symptom reduction does not necessarily mean intact functionality, and to suggest a multidisciplinary approach aimed at achieving the greatest possible reduction of symptoms and normalization of functionality.