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  • ADHD medication proves most effective in treating symptoms, new study finds

    ADHD medication proves most effective in treating symptoms, new study finds

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    In a recent review article published in Pediatrics, researchers provided a comprehensive overview of treatment options available for attention-deficit/hyperactivity disorder (ADHD) for children and adolescent individuals.

    Study: Treatments for ADHD in Children and Adolescents: A Systematic Review. Image Credit: ClareM/Shutterstock.comStudy: Treatments for ADHD in Children and Adolescents: A Systematic Review. Image Credit: ClareM/Shutterstock.com

    Background

    Using a systematic search across medical databases, they identified 312 intervention studies in 540 published articles that studied ADHD interventions lasting more than four weeks for individuals under the age of 18 who had been clinically diagnosed with ADHD.

    The outcomes included health and psychosocial indicators, and included studies compared the intervention group with active, passive, waitlist, placebo, or no treatment groups.

    They found promising evidence regarding the growing availability of several treatments that effectively treat symptoms of ADHD for school-aged and young populations and that while medication continues to be an important form of therapy, it is associated with numerous adverse effects.

    Medications to treat ADHD

    The review evaluated various medications for treating ADHD, including traditional stimulants like methylphenidate and amphetamines, as well as nonstimulants.

    Studies found that traditional stimulants significantly reduced ADHD symptom severity and broad measures but did not notably affect functional impairment.

    While methylphenidate formulations improved symptoms and appetite suppression, it was associated with more adverse events.

    Similarly, amphetamine formulations and norepinephrine reuptake inhibitors (NRIs)  also improved symptoms but suppressed appetite more and had more adverse events, while alpha-agonists were associated with fewer adverse effects.

    Nonstimulants significantly improved ADHD symptoms, broad measures, and disruptive behaviors but did not notably affect functional impairment.

    Direct comparisons between medications showed varied results, with some favoring stimulants over nonstimulants. However, combining nonstimulants with stimulants showed additional small improvements in symptoms.

    Overall, stimulants tended to be more effective in improving ADHD symptoms and broad measures compared to nonstimulants, with some variations in side effects and additional benefits when combined with nonstimulants.

    Integrative, alternative, or complementary therapies such as hippotherapy, homeopathy, and acupuncture were not associated with improvements in symptoms of ADHD or other outcome measures.

    Behavioral ADHD therapies

    Psychosocial interventions significantly improved ADHD symptoms across diverse approaches, including youth-directed interventions, parent support programs, and school-based interventions. However, these treatments did not notably affect disruptive behaviors or academic performance.

    Parent support programs also showed improved broadband scores and disruptive behaviors but not functional impairment.

    School interventions did not significantly affect ADHD symptoms but showed potential for enhancing academic performance.

    Cognitive training did not significantly improve ADHD symptoms but was effective in reducing disruptive behaviors and enhancing broadband measures.

    Neurofeedback, particularly targeting EEG markers, significantly improved ADHD symptoms with minimal heterogeneity, although its impact on disruptive behaviors and functional impairment was inconclusive.

    Overall, these findings suggest the efficacy of psychosocial interventions in alleviating ADHD symptoms in youth, with variations in effectiveness across different approaches and outcomes.

    Combining behavioral treatments and medication

    The reviewers found some studies that combined psychosocial treatments with medication (primarily atomoxetine or stimulants).

    Cognitive behavioral therapy, behavioral therapy, humanistic interventions, solution-focused therapy, and multimodal psychosocial treatments were included as behavioral treatments.

    These studies examined the effect of additional psychosocial treatment compared to medication alone and did not include placebo or no treatment arms.

    There was little evidence that combined therapy improved ADHD symptoms and other outcomes.

    Other key findings

    Nutrition interventions were generally placebo-controlled and included supplements and other dietary treatments, which were often administered in addition to stimulants.

    There were no supplements, including omega-3, which were associated with consistent improvements in outcomes. However, nutritional interventions were generally found to improve symptoms of ADHD and associated disruptive behaviors without increasing adverse effects.

    The study found limited evidence on whether different types of ADHD or coexisting psychiatric conditions influence treatment outcomes. Long-term follow-up data, especially beyond 12 months, were sparse across interventions.

    Studies, including those examining the effect of multimodal treatments, did not show sustained effects beyond 12 months across various interventions, except for some medication trials.

    Conclusions

    The review encompasses a comprehensive analysis of ADHD treatments, highlighting the effectiveness of diverse interventions across multiple domains.

    Medications, including stimulants and nonstimulants, show significant improvements in ADHD symptoms, with moderate to high strength of evidence. Psychosocial treatments, neurofeedback, and nutritional interventions demonstrate varied effectiveness, often with lower strength of evidence.

    Combining treatments was not found to consistently enhance outcomes. There is a dearth of studies on long-term effects and comparative effectiveness, emphasizing the need for more research to inform treatment decisions and improve patient care.

    The authors acknowledged that the scope of their review was limited by their eligibility criteria, excluding some earlier studies, psychosocial interventions, and studies with smaller sample sizes.

    Future research is required to analyze the comparative effectiveness of various treatments with network meta-analysis approaches.

    Journal reference:

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  • Study reveals ADHD medication reduces psychiatric hospitalizations and work disability

    Study reveals ADHD medication reduces psychiatric hospitalizations and work disability

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    Attention-deficit/hyperactivity disorder (ADHD), which causes affected individuals to be impulsive, hyperactive, or inattentive, is typically treated with medications and psychosocial measures. Treatment is associated with numerous benefits, such as reduced suicidal ideation and depression, fewer accidents and inadvertent injuries, as well as better long-term employment statistics.

    Nevertheless, ADHD medication may have potential adverse outcomes like psychotic episodes. A new study in the JAMA Network Open explores the association between ADHD medication and the risk of hospitalization for psychiatric and non-psychiatric reasons.

    Study: Attention-deficit/hyperactivity disorder medications and work disability and mental health outcomes. Image Credit: Alena Kalincheva / Shutterstock.com

    ADHD and stimulants

    While ADHD medications include both stimulants and non-stimulants, stimulants used to treat ADHD have been reported to improve the level of functioning and quality of life. Short-term trial meta-analysis data indicates the first choice of ADHD stimulants in adults is amphetamine, whereas methylphenidate is often used for treating adolescents and children.

    More research is needed to determine the long-term safety of these therapeutics, particularly in regard to their ability to increase blood pressure and heart rate, cause seizures, and trigger psychosis or mania. Moreover, whether these agents continue to be effective over time remains unknown.

    To date, little research has elucidated the efficacy of these stimulants in reducing work disability. Work disability is defined as absence from work due to sickness, with or without a disability pension.

    About the study

    The current Swedish study obtained data from national registries of inpatients and outpatients and those who took medical leave or obtained disability pensions. Over 221,700 individuals between 16 and 65 years of age with a diagnosis of ADHD were included in the study, 55% of whom were male with a mean age of 25 years.

    Psychiatric and non-psychiatric hospitalization rates, suicides and attempts, and work disability were assessed, as well as measures of long-term outcomes in ADHD patients on medication.

    Study findings

    Among the most common medications for ADHD were methylphenidate, which was prescribed to about 70% of patients, followed by lisdexamphetamine, which was used by 35% of patients.

    The mean follow-up period was seven years. Over 25% of treated individuals were hospitalized for psychiatric illness during the follow-up period.

    The risk of hospitalization for psychiatric illness was reduced by 25% and 20% with amphetamine and lisdexamphetamine treatment, respectively. Amphetamine appeared to be more effective in adults, whereas dexamphetamine was more effective among adolescents and young adults.

    Other drugs with a favorable but smaller effect included combinations of ADHD drugs, with a 15% reduced risk, and dexamphetamine and methylphenidate, with a reduction of approximately 10% each. Methylphenidate was associated with increased effectiveness among the younger age groups; however, this medication was not associated with any discernible benefits in adults.

    The lower effectiveness of methylphenidate in adults could be due to the temporal reduction of efficacy with long-term use, as this drug is typically used as a first-line treatment.

    Drugs like modafinil, atomoxetine, clonidine, and guanfacine did not show any association with hospitalization risk. No drug was associated with a greater risk of hospitalization for reasons other than psychiatric.

    In contrast, some drugs or combinations, including amphetamine, lisdexamphetamine, polytherapy, dexamphetamine, methylphenidate, and atomoxetine, were associated with a lower risk of non-psychiatric hospitalization.

    Other favorable outcomes associated with dexamphetamine, lisdexamphetamine, and methylphenidate included a reduced risk of suicidal behavior by 30%, 25%, and about 10%, respectively. Suicidal behavior was 20% more common in individuals treated with atomoxetine, which is a non-stimulant drug that may be prescribed when stimulants are contraindicated or the patient is unwilling to use stimulants.

    ADHD individuals prescribed atomoxetine reported about 10% less disability than those not on this drug. This was particularly notable among patients 29 years of age and younger who had a 20% reduced risk of work disability. This effect was more significant among males at 15%, whereas its effects were insignificant among females. Methylphenidate produced similar but weaker effects at 10% in the same population.

    Atomoxetine may be prescribed for individuals with less severe ADHD, which explains the lower work disability in this group. Importantly, stimulant-associated adverse effects could also be present, which may negatively impact the work ability of those prescribed these medications. Alternatively, individuals with ADHD may have reached the point of work disability before the study began.

    What are the implications?

    The current study is the first to examine individual medications for their effectiveness in ADHD. Overall, a positive association was observed between medications like amphetamines and methylphenidate and psychiatric outcomes. The risk of cardiovascular disease or events, seizures, and unintentional injury appears to decrease on ADHD medication.

    ADHD medication use can reduce morbidity in adolescents and adults with ADHD.”

    Journal reference:

    • Taipale, H., Bergstrom, J., and Gemes, K. (2024). Attention-deficit/hyperactivity disorder medications and work disability and mental health outcomes. JAMA Network Open 7(3);e242859. doi:10.1001/jamanetworkopen.2024.2859

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  • Understanding giggle incontinence: Causes, symptoms, and management

    Understanding giggle incontinence: Causes, symptoms, and management

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    A recent review published in the journal Pediatric Research discusses the historical background and current understanding of giggle incontinence, which is a bladder storage disorder.

    Study: Giggle incontinence: a scoping review. Image Credit: Pavlova Yuliia / Shutterstock.com

    What is giggle incontinence?

    Giggle incontinence is a type of daytime urinary incontinence characterized by uncontrollable episodes of urinary incontinence due to loud, powerful, or bursting laughter. Unlike enuresis, stress urinary incontinence, non-neurogenic voiding dysfunction, bladder and bowel dysfunction, or anatomical disorders causing incontinence, giggle incontinence lacks additional functional symptoms.

    Historically, giggle incontinence has been mistaken for stress urinary incontinence and an overactive bladder. Moreover, giggle incontinence has been considered a particular type of laughter-induced daytime urinary incontinence that can be distinguished from laughter-induced stress urinary incontinence by its specific feature of complete emptying of the bladder.

    The exact etiology of giggle incontinence is not fully understood. However, two main hypotheses indicate the involvement of the central nervous system and dysfunction of the detrusor and pelvic floor muscles.

    The authors of the current review systematically searched various scientific databases and identified 26 studies on giggle incontinence published between 1959 and 2023. These studies were assessed to describe the historical background, current understanding, and challenges associated with giggle incontinence.   

    Different types of urinary incontinence in children

    Various terminologies have been used to describe giggle incontinence, including micturition induced by giggling, ambivalent laughter micturition, and enuresis risoria. To better understand giggle incontinence and develop appropriate treatments, it is important to distinguish the clinical consequences of giggle incontinence from those associated with stress urinary incontinence and an overactive bladder.

    According to the International Children’s Continence Society (ICCS), stress urinary incontinence is characterized by the involuntary loss of urine due to activities that increase intra-abdominal pressure, such as sneezing, coughing, or laughter. Current estimates indicate that stress urinary incontinence affects 8-19% of children.

    An overactive bladder is characterized by minor and frequent micturition, as well as other symptoms, including urgency, pollakiuria, and incontinence. This condition affects 5-12% of children.   

    ICCS describes giggle incontinence as a rare disorder marked by significant voiding during or after laughter, while bladder function remains normal in its absence. The condition is characterized by laughter-induced uncontrollable urine loss that cannot be stopped until the bladder is completely emptied. However, the condition is not associated with any concurrent urological disorders.    

    By analyzing 26 studies that reported a total of 351 giggle incontinence cases since 1959, giggle incontinence primarily affects females, with some cases reporting a family history of this condition. Giggle incontinence primarily affects children over five years of age and often improves or disappears with age.

    Pathophysiology

    A widely accepted hypothesis on the pathogenesis of giggle incontinence indicates the involvement of the central nervous system, similar to cataplexy, which is the loss of voluntary muscle control. Laughter acts as a stimulus to induce hypotonia and relaxation of pelvic floor muscles, thereby leading to uncontrolled micturition.

    Mechanistic evidence links cataplexy with type 1 narcolepsy-associated laughter-induced muscle weakness. Most patients with type 1 narcolepsy are positive for the human leukocyte antigen HLA-DQB1*06:02, which may contribute to the familial tendency observed in some giggle incontinence patients.

    Attention-deficit hyperactivity disorder (ADHD) is a common condition observed in about 23% of giggle incontinence patients. Existing evidence also links giggle incontinence pathogenesis with pelvic floor muscle dysfunction, as the proper functioning of these muscles is required for the closing of vaginal, urethral, and anal sphincters in response to increased intra-abdominal pressure. It has also been hypothesized that laughter-induced instability of the detrusor muscle can lead to giggle incontinence.

    Diagnosis

    A detailed voiding history is crucial for diagnosing diverse forms of daytime urinary incontinence. This will typically include a detailed patient history, maintenance of a voiding diary, analysis of urinary tract infection history, evaluation of toileting positions, and thorough physical examination of the abdominal, genital, and lumbosacral regions.

    These procedures should be combined with lower urinary tract ultrasound, voiding residual analysis, and electromyographic flowmetry for an accurate diagnosis of lower urinary tract dysfunction. However, these examinations often provide normal results in patients with giggle incontinence.  

    Existing evidence highlights a connection between giggle incontinence and overactive bladder waves. However, urodynamic studies have defined overactive bladder waves as sensitive hyperactive waves, whereas giggle incontinence waves are considered asymptomatic hyperactive waves. Laughter-induced asymptomatic hyperactive waves may justify the urgent and spontaneous urination in giggle incontinence patients and distinguish it from the sensitive hyperactivity waves observed in overactive bladder.

    Treatment

    Medications that are commonly used to treat neurodynamic lower urinary tract disorders include anticonvulsants, antidepressants, anticholinergics, α-adrenergic blockers, and electric shocks. Three therapies are currently being used to control incontinence, including standard urotherapy, biofeedback, and methylphenidate.

    Previous studies have shown that six-month standard urotherapy can partially improve giggle incontinence in 33% of patients; however, this therapy failed to cure the condition. Patients who are unresponsive to standard urotherapy are typically advised to undergo specific urotherapy.

    Studies using biofeedback for giggle incontinence patients have reported an efficacy rate of 73% after ten weeks of weekly sessions. Patients are often advised to continue biofeedback training alone or in combination with methylphenidate once continence is achieved.

    Methylphenidate is a central nervous system stimulant that acts by influencing urethral smooth muscles and increasing dopamine activity in the brain. Methylphenidate has been found to completely resolve giggle incontinence symptoms in patients; however, the treatment may cause adverse side effects in some patients, including insomnia, tachycardia, hypertension, anorexia, weight loss, abdominal pain, headache, irritability, agitation, or anxiety.  

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