Category Archives: Child health

Treatment of Attention-Deficit/Hyperactivity Disorder in AdolescentsA Systematic Review

Original article can be found here: http://jama.jamanetwork.com/article.aspx?articleID=2520634

Eugenia Chan, MD, MPH1,3; Jason M. Fogler, PhD1,2,3; Paul G. Hammerness, MD2,3
JAMA. 2016;315(18):1997-2008. doi:10.1001/jama.2016.5453.
 ABSTRACT

Importance  Although attention-deficit/hyperactivity disorder (ADHD) is highly prevalent in adolescents and often persists into adulthood, most studies about treatment were performed in children. Less is known about ADHD treatment in adolescents.

Objective  To review the evidence for pharmacological and psychosocial treatment of ADHD in adolescents.

Evidence Review  The databases of CINAHL Plus, MEDLINE, PsycINFO, ERIC, and the Cochrane Database of Systematic Reviews were searched for articles published between January 1, 1999, and January 31, 2016, on ADHD treatment in adolescents. Additional studies were identified by hand-searching reference lists of retrieved articles. Study quality was rated using McMaster University Effective Public Health Practice Project criteria. The evidence level for treatment recommendations was based on Oxford Centre for Evidence-Based Medicine criteria.

Findings  Sixteen randomized clinical trials and 1 meta-analysis, involving 2668 participants, of pharmacological and psychosocial treatments for ADHD in adolescents aged 12 years to 18 years were included. Evidence of efficacy was stronger for the extended-release methylphenidate and amphetamine class stimulant medications (level 1B based on Oxford Centre for Evidence-Based Medicine criteria) and atomoxetine than for the extended-release α2-adrenergic agonists guanfacine or clonidine (no studies). For the primary efficacy measure of total symptom score on the ADHD Rating Scale (score range, 0 [least symptomatic] to 54 [most symptomatic]), both stimulant and nonstimulant medications led to clinically significant reductions of 14.93 to 24.60 absolute points. The psychosocial treatments combining behavioral, cognitive behavioral, and skills training techniques demonstrated small- to medium-sized improvements (range for mean SD difference in Cohen d, 0.30-0.69) for parent-rated ADHD symptoms, co-occurring emotional or behavioral symptoms, and interpersonal functioning. Psychosocial treatments were associated with more robust (Cohen d range, 0.51-5.15) improvements in academic and organizational skills, such as homework completion and planner use.

Conclusions and Relevance  Evidence supports the use of extended-release methylphenidate and amphetamine formulations, atomoxetine, and extended-release guanfacine to improve symptoms of ADHD in adolescents. Psychosocial treatments incorporating behavior contingency management, motivational enhancement, and academic, organizational, and social skills training techniques were associated with inconsistent effects on ADHD symptoms and greater benefit for academic and organizational skills. Additional treatment studies in adolescents, including combined pharmacological and psychosocial treatments, are needed.

Smoke-free legislation associated with better child and perinatal health

Clinical Question:  How much does smoke-free legislation impact the health of children?

The passage of smoke-free legislation is associated with nearly immediate and meaningful improvements in the number of preterm births and asthma exacerbations. (LOE = 1a)Bottom Line

Reference

Been JV, Nurmatov UB, Cox B, Nawrot TS, van Schayck CP, Sheikh A. Effect of smoke-free legislation on perinatal and child health: a systematic review and meta-analysis. Lancet 2014;383(9928):1549-1560.

Study DesignMeta-analysis (randomized controlled trials)

FundingFoundation

SettingVarious (meta-analysis)

AllocationUnknown

Synopsis

These authors searched many databases, including trials registries, to identify published and unpublished studies that evaluated the effects of smoke-free legislation on preterm birth, low birth weight, and asthma. Ultimately they included 11 studies (5 North American and 6 European) with more than 2.5 million births and nearly a quarter million asthma exacerbations! Nearly all the legislation required comprehensive and immediate changes (as opposed to the step-wise implementation used in Belgium). Four studies were deemed to have low risk of bias, 6 had moderate risk, and 1 had high risk. The higher-quality studies tended to be from Europe and the legislations invoked national-level bans on tobacco use. In 4 studies with nearly 1.4 million births, smoke-free legislation was associated with a 10% relative decrease in the frequency of preterm birth immediately after the legislation, and that result was maintained. However, the legislation had no impact on the frequency of low-birth-weight infants (6 studies with nearly 2 million participants). In 3 studies with more than 240,000 events, legislation was associated with an immediate 10% drop in the rate of hospital attendance for asthma exacerbations. There was no statistically significant subsequent decline, though. The authors provide additional data on secondary outcomes, such as small for gestational age, birth defects, and so forth, most of which were inconsistently studied and showed inconsistent results.

Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI