July 29, 2024
Quality of life (QoL) is defined as a person’s satisfaction with their life, measured across several dimensions including psychological, social, health, biological, and economic wellbeing. For adults, these are usually self-reported. In children and adolescents, they tend to be reported indirectly through parent- or caregiver questionnaires.
Medications for ADHD include stimulants (methylphenidate and amphetamines) and non-stimulants (e.g., atomoxetine, clonidine, guanfacine, viloxazine). As QoL is related to ADHD symptoms’ severity, management of ADHD via medication could improve not only core symptoms but also QoL in people with ADHD.
Noting the absence of meta-analytic evidence on the effects of ADHD medications on QoL, an international research team conducted a systematic review and meta-analysis of parallel or cross-over randomized clinical trials (RCTs) to estimate the effects of ADHD medication on QoL. They also performed secondary analyses to see if these effects differed in children and adolescents versus adults, as well as by class of medications, and if they were moderated by length of treatment.
Meta-analysis of four RCTs with a combined total of 950 participants with ADHD (45% adults) found a medium effect size improvement among those receiving amphetamines by comparison with those receiving placebo. There was no sign of publication bias, but there was wide variation (heterogeneity) in effect size estimated among the studies.
Meta-analysis of four RCTs with a combined total of 1,094 participants with ADHD (57% adults) found a small-to-medium effect size improvement among those receiving methylphenidate by comparison with those receiving placebo. Again, there was no sign of publication bias, but wide variation in effect sizes among the studies.
The team could not explore whether length of treatment with the stimulants methylphenidate or amphetamines affected the results, or a subgroup analysis to test any differences in effects on QoL between children/adolescents and adults, since less than ten studies were included in each of the meta-analyses.
Finally, meta-analysis of eleven RCTs with a combined total of 3,344 participants with ADHD (63% adults) likewise found a small effect size improvement among those taking atomoxetine compared with those receiving placebo. Once again, there was no sign of publication bias, but wide variation in effect sizes among the studies.
With more than ten studies, the team was able to establish that for atomoxetine treatment, length of intervention – the studies ranged from 6 to 24 weeks – had no significant moderating effect. Similarly, they found no significant differences in effect on children and adolescents versus adults.
A single RCT evaluating modafinil (a less addictive stimulant) treatment in adults found no improvements at any dose, whereas a single RCT testing non-stimulant guanfacine reported a medium effect size improvement in QoL.
The team concluded, “Overall, we found that methylphenidate, amphetamines, and atomoxetine were significantly more efficacious than placebo in improving QoL in people with ADHD. For atomoxetine, efficacy was significantly detected regardless of length of intervention or participant age ... our study demonstrated that, besides being efficacious in reducing ADHD symptomatology, stimulant and non-stimulant medications are effective in improving QoL in children, young people, and adults with ADHD, albeit with smaller effects compared those found for ADHD core symptoms severity. We found a medium effect for amphetamines and methylphenidate (both stimulant medications), and a small effect for atomoxetine (a non-stimulant).”
Alessio Bellato, Nadia J. Perrott, Lucia Marzulli, Valeria Parlatini, David Coghill, and Samuele Cortese, “Systematic Review and Meta-Analysis: Effects of Pharmacological Treatment for Attention-Deficit/Hyperactivity Disorder on Quality of Life,” Journal of the American Academy of Child & Adolescent Psychiatry (2024), https://doi.org/10.1016/j.jaac.2024.05.023.
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Previous studies have examined how stimulant medications affect the brain in controlled settings, but less is known about their impact in real-world conditions, where children may not always take their medication consistently or may combine it with other treatments. A new study leverages data from the Adolescent Brain Cognitive Development (ABCD) study to explore how real-world stimulant use impacts brain connectivity and ADHD symptoms over two years.
Changes in Brain Connectivity Researchers used brain imaging data from the ABCD study to examine the functional connectivity—communication between brain areas—of six regions within the striatum, a brain area involved in motivation and movement control. They focused on how stimulant use influenced connectivity between the striatum and other networks involved in executive functioning and visual-motor control.
The study found that stimulant exposure was linked to reduced connectivity between key striatal areas (such as the caudate and putamen) and large brain networks, including the frontoparietal and visual networks. These changes were more pronounced in children taking stimulants compared to those who were not medicated, as well as compared to typically developing children. Importantly, this reduction in connectivity seemed to regulate certain brain networks that are typically altered in children with ADHD.
Symptom Improvement In addition to brain changes, 14% of children taking stimulants experienced a significant reduction in ADHD symptoms over the two-year period. These children showed the strongest connectivity reductions between the right putamen and the visual network, suggesting that stimulant-induced connectivity changes may contribute to improvements in visual attentional control, which is a common challenge for children with ADHD.
Why This Matters This study is one of the first to examine how stimulant use in real-world conditions affects brain networks in children with ADHD over time. The findings suggest that stimulants may help normalize certain connectivity patterns associated with ADHD, particularly in networks related to attention and control. These insights could help clinicians better understand the potential long-term effects of stimulant treatment and guide personalized approaches to ADHD management.
Conclusion Stimulant medications appear to alter striatal-cortical connectivity in children with ADHD, with some changes linked to symptom improvement. This research highlights the potential for stimulant medications to impact brain networks in ways that support attention and control, highlighting the importance of understanding how real-world medication use influences ADHD treatment outcomes.
The Neuroeconomic Perspective
Neuroeconomics combines neuroscience, psychology, and economics to understand how people make decisions. Neuroeconomic studies suggest that brain regions responsible for evaluating risk and reward, including the prefrontal cortex and dopamine pathways, function differently in individuals with ADHD. These insights are crucial for developing more tailored interventions. For example, understanding how ADHD affects reward processing might inform strategies that help individuals resist impulsive choices or increase motivation for delayed rewards.
Understanding Decision-Making in ADHD
We know that decision-making is a sophisticated process involving various cognitive procedures. It’s not just about choosing between options but also about how to weigh risks, rewards, and potential future outcomes; Attention, motivation, and cognitive control are core to this process. For individuals with ADHD, however, this neural framework is affected by impairments in attention and impulse control, often resulting in “delay discounting”—the tendency to prefer smaller, immediate rewards over larger, delayed ones.
This propensity for impulsive decisions is more than a personal challenge; it has broader societal and economic implications. Previous studies have shown that these tendencies in ADHD can lead to issues in academics, work, finances, and personal relationships, emphasizing the need for targeted support and interventions.
Implications and Future Directions
This review highlights a need for continued research to bridge the gaps in understanding how ADHD-specific cognitive deficits influence decision-making. Viewing ADHD through a neuroeconomic lens clarifies how cognitive and neural differences affect decision-making, often leading to impulsive choices with economic and social impacts. This perspective opens doors to more effective interventions, improving decision-making for individuals with ADHD. Future policies informed by this approach could enhance support and reduce associated societal costs.
Children with ADHD face significant challenges in academic and social settings, often including difficult interactions with teachers. This meta-analysis investigates the quality of student-teacher relationships for children with ADHD, focusing on two key dimensions: closeness and conflict. By synthesizing data from 27 studies encompassing 17,236 participants, the study aims to provide a comprehensive understanding of these dynamics and inform interventions to support both students and teachers.
A systematic review was conducted using databases such as PsycInfo, ERIC, and ProQuest. Researchers identified 47 effect sizes from 27 studies, examining the association between ADHD symptoms and the quality of student-teacher relationships. Relationship quality was assessed through two primary dimensions:
Eight moderator analyses were also performed to explore how factors like grade level, gender, ADHD presentation, and comorbid conditions influenced these relationships.
The findings reveal that children with ADHD symptoms typically experience relationships with teachers characterized by lower levels of closeness and higher levels of conflict. Notably, externalizing behaviors such as hyperactivity and impulsivity are more strongly associated with conflict than inattentive symptoms. Moderator analyses showed that factors like gender, ADHD presentation, and age influence the severity of these relationship dynamics. For instance, younger children and those with hyperactive-impulsive presentations tend to have higher conflict levels with teachers.
Additionally, the research emphasizes the reciprocal nature of these relationships: ADHD symptoms may exacerbate teacher frustration, while negative teacher-student interactions can intensify student behavioral challenges.
Conclusion
This meta-analysis highlights the critical role of student-teacher relationships in the development of children with ADHD. The findings underline the need for targeted interventions that foster positive teacher-student interactions and reduce conflict. Addressing these relationship dynamics could enhance academic performance, social integration, and emotional well-being for children with ADHD. Future research should explore the causal pathways between ADHD symptoms and relationship quality to better inform educational strategies and support systems.
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