January 15, 2024

Nationwide population studies: atomoxetine not associated with birth defects

Treatment for ADHD among women of reproductive age is increasingly common. 

That means we need to know whether ADHD medications have any tendency to increase the risk of birth defects. Previous studies have looked mostly at ADHD medications that are central nervous system stimulants, especially methylphenidate and amphetamines.

Atomoxetine is the most widely prescribed non-stimulant for treating ADHD. It acts indirectly, by selectively inhibiting the removal of norepinephrine, a neurotransmitter that mobilizes the brain and body for action. 

To explore whether atomoxetine might be associated with any higher risk of birth defects, an international study team examined nationwide population data from four Nordic countries with universal single-payer health insurance systems – Denmark, Norway, Sweden, and Iceland – along with nationwide data from the U.S. Medicaid system, which is likewise single-payer, and covers roughly half of all births in the U.S.

They compared the prevalence of major birth defects among infants born to women exposed to atomoxetine in the first trimester (three months) of pregnancy to the prevalence among infants born to women not exposed to any ADHD drug during the period beginning three months before their last menstrual period and concluding at the end of the first trimester.

The team adjusted for maternal characteristics such as maternal age, calendar year of delivery, childbirth and medical characteristics, psychiatric conditions, high blood pressure, diabetes, kidney disease, obesity, and smoking.

In more than 2.4 million births in the four Nordic countries, and almost 1.8 million births in the U.S., there was absolutely no sign of increased prevalence of major infant malformations among infants born to mothers taking atomoxetine. 

More specifically looking at heart defects, there was again no significant association with maternal atomoxetine use, either in the Nordic population, the U.S. population, or the combined populations.

For limb malformations, there was again no significant association between maternal atomoxetine use and birth defects in the combined populations. There was an appearance of a significant association in the Nordic population, but that was based on only 5 instances, and because there were zero instances in the U.S. population, there was no net association at all in the combined population of more than 4.2 million.

The team concluded, “We found no increased prevalence of major congenital malformations overall associated with atomoxetine use in early pregnancy. The increased prevalence of limb malformations in the Nordic countries was not observed in the US. … Given the low absolute risk of both of these outcomes, these results are reassuring from a public health perspective and provide important information in the consideration of whether to continue treatment with atomoxetine during pregnancy.”

Gabriella Bröms, Sonia Hernandez-Diaz, Krista F. Huybrechts, Brian T. Bateman, Eskild Bendix Kristiansen, Kristjana Einarsdóttir, Anders Engeland, Kari Furu, Mika Gissler, Pär Karlsson, Kari Klungsøyr, Anna-Maria Lahesmaa-Korpinen, Helen Mogun, Mette Nørgaard, Johan Reutfors, Henrik Toft Sørensen, Helga Zoega, MA, and Helle Kieler, “Atomoxetine in Early Pregnancy and the Prevalence of Major Congenital Malformations: A Multinational Study,” Journal of Clinical Psychiatry (2023) 84(1): 22m14430, https://doi.org/10.4088/JCP.22m14430.

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News Tuesday: Fidgeting and ADHD

A recent study delved into the connection between fidgeting and cognitive performance in adults with Attention-Deficit/Hyperactivity Disorder. Recognizing that hyperactivity often manifests as fidgeting, the researchers sought to understand its role in attention and performance during cognitively demanding tasks. They designed a framework to quantify meaningful fidgeting variables using actigraphy devices.

(Note: Actigraphy is a non-invasive method of monitoring human rest/activity cycles. It involves the use of a small, wearable device called an actigraph or actimetry sensor, typically worn on the wrist, similar to a watch. The actigraph records movement data over extended periods, often days to weeks, to track sleep patterns, activity levels, and circadian rhythms. In this study, actigraphy devices were used to measure fidgeting by recording the participants' movements continuously during the cognitive task. This data provided objective, quantitative measures of fidgeting, allowing the researchers to analyze its relationship with attention and task performance.)

The study involved 70 adult participants aged 18-50, all diagnosed with ADHD. Participants underwent a thorough screening process, including clinical interviews and ADHD symptom ratings. The analysis revealed that fidgeting increased during correct trials, particularly in participants with consistent reaction times, suggesting that fidgeting helps sustain attention. Interestingly, fidgeting patterns varied between early and later trials, further highlighting its role in maintaining focus over time.

Additionally, a correlation analysis validated the relevance of the newly defined fidget variables with ADHD symptom severity. This finding suggests that fidgeting may act as a compensatory mechanism for individuals with ADHD, aiding in their ability to maintain attention during tasks requiring cognitive control.

This study provides valuable insights into the role of fidgeting in adults with ADHD, suggesting that it may help sustain attention during challenging cognitive tasks. By introducing and validating new fidget variables, the researchers hope to standardize future quantitative research in this area. Understanding the compensatory role of fidgeting can lead to better management strategies for ADHD, emphasizing the potential benefits of movement for maintaining focus.

July 16, 2024

Identifying Autistic-Like Symptoms in Children with ADHD

NEWS TUESDAY: Identifying Autistic-Like Symptoms in Children with ADHD

A recent study investigated the presence of autistic-like symptoms in children diagnosed with Attention Deficit/Hyperactivity Disorder (ADHD). Given the overlapping social difficulties in both ADHD and Autism Spectrum Disorder (ASD), distinguishing between the two disorders can be challenging. This study aims to pinpoint specific patterns of autistic symptoms in children with ADHD, comparing them to those with ASD using the Autism Diagnostic Observation Schedule, 2nd edition (ADOS-2).

The research involved 43 school-age children divided into two groups:

  • ADHD Group (25 children): Initially referred for ASD symptoms but later diagnosed with ADHD.
  • ASD Group (18 children): Children diagnosed with ASD.

Researchers used ADOS-2 to evaluate differences in communication deficits, social interaction challenges, and repetitive behaviors between the two groups. The study also compared IQ, age, ADOS-2 domain scores, and externalizing/internalizing problems.

Key Findings:

  • Significant differences were found between the ADHD and ASD groups in ADOS-2 domain scores, including Social Affect, Restricted and Repetitive Behavior, and Total Score.
  • On an individual item level, children with ADHD displayed similar atypical behaviors as those with ASD in social-communication areas such as "Pointing" and "Gestures".
  • Both groups showed comparable frequencies in behaviors like "Stereotyped/idiosyncratic words or phrases", "Mannerisms", and "Repetitive interests and behaviors".

The study highlights the importance of identifying transdiagnostic domains that overlap between ADHD and ASD. The transdiagnostic domain refers to a set of symptoms or behaviors that are common across multiple diagnostic categories rather than being specific to just one. Identifying these domains in mental health practice and in psychological research is crucial to understanding, properly diagnosing, and treating conditions with overlapping features. This understanding could pave the way for tailored treatments addressing the specific needs of children with ADHD, particularly those exhibiting autistic-like symptoms.

July 9, 2024

Non-stimulant Medications for Adults with ADHD: An Overview

NEW STUDY: Non-stimulant Medications for Adults with ADHD: An Overview

Attention-Deficit/Hyperactivity Disorder (ADHD) in adults is commonly treated with stimulant medications such as methylphenidate and amphetamines. However, not all patients respond well to these stimulants or tolerate them effectively. For such cases, non-stimulant medications provide an alternative treatment approach.

Recent research by Brancati et al. reviews the efficacy and safety of non-stimulant medications for adult ADHD. Atomoxetine, a well-studied non-stimulant, has shown significant effectiveness in treating ADHD symptoms in adults. The review highlights the importance of considering dosage, treatment duration, safety, and the presence of psychiatric comorbidities when prescribing atomoxetine.

Additionally, certain antidepressants, including tricyclic compounds, bupropion, and viloxazine, which possess noradrenergic or dopaminergic properties, have demonstrated efficacy in managing adult ADHD. Antihypertensive medications, especially guanfacine, have also been found effective. Other medications like memantine, metadoxine, and mood stabilizers show promise, whereas treatments like galantamine, antipsychotics, and cannabinoids have not yielded positive results.

The expert opinion section of the review emphasizes that while clinical guidelines primarily recommend atomoxetine as a second-line treatment, several other non-stimulant options can be utilized to tailor treatments based on individual patient needs and comorbid conditions. Despite these advancements, the authors call for further research to develop and refine more personalized treatment strategies for adults with ADHD.

This review underscores the growing landscape of non-stimulant treatment options, offering hope for more personalized and effective management of ADHD in adults.

June 25, 2024