Sequential Pharmacotherapy for Children With Comorbid Attention-Deficit/Hyperactivity and Anxiety Disorders
Attention-deficit/hyperactivity disorder (ADHD) is often accompanied by clinically significant anxiety, but few empirical data guide treatment of children meeting full DSM-IV criteria for ADHD and anxiety disorders (ADHD/ANX). This study examined the efficacy of sequential pharmacotherapy for ADHD/ANX children.
Children, age 6 to 17 years, with ADHD/ANX were titrated to optimal methylphenidate dose and assessed along with children who entered the study on a previously optimized stimulant. Children with improved ADHD who remained anxious were randomly assigned to 8 weeks of double-blind stimulant + fluvoxamine (STIM/FLV) or stimulant + placebo (STIM/PL). Primary efficacy measures were the Swanson, Nolan, Atkins, and Pelham IV Parent and Teacher Rating Scale ADHD score and the Pediatric Anxiety Rating Scale total score. ADHD, ANX, and overall Clinical Global Impressions-Improvement scores were also obtained.
Of the 32 medication-naive children openly treated with methylphenidate, 26 (81%) improved as to ADHD. Twenty-five children entered the randomized trial. Intent-to-treat analysis indicated no differences between the STIM/FLV (n = 15) and STIM/PL groups on the Pediatric Anxiety Rating Scale or Clinical Global Impressions-Improvement-defined responder rate. Medications in both arms were well tolerated.
Children with ADHD/ANX have a response rate to stimulants for ADHD that is comparable with that of children with general ADHD. The benefit of adding FLV to stimulants for ANX remains unproven.
Available from: Abraham Weizman
- "MPH treatment in our study was well tolerated and safe; none of the participants reported intolerable side effects that would cause termination of the MPH treatment. These findings are consistent with previous studies that demonstrated the safety of stimulant treatment in ADHD pediatric patients with comorbid anxiety disorders (Diamond et al., 1999; Abikoff et al., 2005). "
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ABSTRACT: The aim of this study was to assess the response of social phobia (SP) symptoms to methylphenidate (MPH) treatment in children with attention deficit hyperactivity disorder (ADHD). Twenty-one ADHD patients with SP, aged between 8 and 18 years, received 12 weeks of MPH treatment. The severity of SP symptoms were assessed by the Liebowitz Social Anxiety Scale for Children and Adolescents (LSAS-CA), and the severity of ADHD symptoms was assessed by the ADHD Rating Scale at baseline and at endpoint. MPH treatment was associated with a significant decrease in the ADHD Rating Scale scores (P<0.0001) and in the total LSAS-CA scores (P=0.013), as well as the school-related items of LSAS-CA (P=0.011). A significant correlation was found between the reductions in ADHD score and total LSAS-CA score (P=0.038), especially in school-related SP. The improvement in ADHD symptoms because of MPH treatment correlates with a parallel improvement in SP. MPH treatment appears to be safe and effective in ADHD/SP children.
Available from: Matthew A Jarrett
- "At the same time, current research has shown that stimulant treatment for children with ADHD and anxiety often results in improvements in ADHD but not changes in anxiety symptoms at the group level (Abikoff et al., 2005). At the individual level, though, Abikoff et al. (2005) did find some children who responded to stimulant medication for both ADHD and anxiety symptoms. Future stimulant medication studies might be able to offer unique examinations of the temporal relationships between ADHD and anxiety symptoms over the course of stimulant treatment, since symptom change might be more tightly coupled with stimulant medication treatment than behavioral treatment (i.e., the intervention is more closely related to symptoms than psychosocial treatment). "
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ABSTRACT: Approximately 30%-40% of children with attention-deficit/hyperactivity disorder (ADHD) meet criteria for a comorbid anxiety disorder in clinical samples (Tannock, 2009), but little is known about treatment response for this subgroup. The current study evaluated processes of change in a psychosocial treatment designed for children with ADHD and anxiety (Jarrett & Ollendick, 2012). Processes included the slope of symptom change during treatment, the temporal relations between ADHD and anxiety symptoms during treatment, and changes in neurocognitive functioning, parent-child relationships, and family functioning. Treatment involved a combination of parent management training for ADHD and family based cognitive-behavioral therapy for anxiety. Sessions lasted approximately 90 min, and the treatment consisted of 10 weekly sessions. Eight children ages 8-12 with ADHD, combined type (ADHD-C), and at least 1 of 3 anxiety disorders (separation anxiety disorder, generalized anxiety disorder, social phobia) were selected for the study. The study utilized a single-case design with weekly measures of ADHD and anxiety symptoms along with pretreatment, midtreatment, and 1-week posttreatment assessments. Slopes of symptom change and temporal relationships among symptom domains were examined using simulation modeling analysis (Borckardt et al., 2008), while other analyses involved standard comparisons across time points. Results generally supported declining slopes for ADHD and anxiety and greater concurrent change between anxiety and hyperactivity/impulsivity than anxiety and inattention. Few changes were found for neurocognitive functioning, but some changes were found for parent-child relationships and family functioning. Future studies are needed to better understand the treatment of ADHD and comorbid anxiety. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
Available from: Jan Buitelaar
- "Similarly, a 4-month, randomized, placebo-controlled trial, conducted in 91 children with ADHD, 38 of whom had comorbid anxiety, found that, when MPH dose is titrated as in standard clinical practice, the presence of comorbid anxiety influenced neither the efficacy nor the associated side effects of MPH treatment . Furthermore, a study investigating the efficacy of sequential pharmacotherapy in 42 children with ADHD and comorbid anxiety not only found that response to MPH treatment was comparable with that observed in children with general ADHD, but also that a small but significant minority of children exhibited a clinically meaningful reduction in anxiety following treatment with stimulant monotherapy . Suggested reasons for these discrepancies include differences in study design (e.g. the MTA study included individualised titration, 14 months of treatment and a monthly management strategy), in contrast to the short-term, fixed-dose designs of earlier investigations  and the fact that children with ADHD and comorbid anxiety are likely to present with more physiological symptoms than those without comorbid anxiety, which may be overlooked at the time of treatment initiation and subsequently incorrectly attributed to the treatment itself . "
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ABSTRACT: Attention-deficit/hyperactivity disorder (ADHD), one of the most common neuropsychiatric conditions of childhood, often has a chronic course and persists into adulthood in many individuals. ADHD may have a clinically important impact on health-related quality of life in children, a significant impact on parents' emotional health and interfere with family activities/cohesion. To date, the main targets of ADHD treatment have focused on reducing the severity of symptoms during the school day and improving academic performance. However, the treatment of ADHD should reach beyond symptom control to address the issues of social competencies and improvement of health-related quality of life from the perspectives of individuals with ADHD and their families, to support them in reaching their full developmental potential. Methylphenidate (MPH) is recognised as the first-line choice of pharmacotherapy for ADHD in children and adolescents. This paper focuses on the importance and benefits to child development of ADHD symptom control beyond the school day only, i.e. extending into late afternoon and evening and uses the example of an extended-release MPH formulation (OROS((R)) MPH) to demonstrate the potential benefits of active full day coverage (12 h) with a single daily dose. Concerns of long-term stimulant treatment are also discussed.
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