Stimulant medications are the most prevalent first-line pharmacotherapy for attention-deficit/hyperactivity disorder, but children with aggressive behavior often receive multiagent treatment. There ...is sparse evidence for the benefits of adjunctive medications when stimulant monotherapy provides inadequate benefit for aggressive behavior, yet the adverse effects of common adjuncts are well established. This study compared the efficacy in reducing aggressive behavior of risperidone (RISP), divalproex sodium (DVPX), and placebo (PBO) added to stimulant medication among childrenwhose symptoms persisted after individually optimized stimulant treatment.
This trial enrolled 6- to 12-year-old with attention-deficit/hyperactivity disorder, a disruptive disorder, significant aggressive behavior, and prior stimulant treatment. Open, systematically titrated stimulant treatment identified patients with inadequate reductions in aggressive behavior, who were then randomly assigned to receive adjunctive RISP, DVPX, or PBO under double-blinded conditions for 8 weeks. Family-based behavioral treatment was offered throughout the trial. The primary outcome was the parent-completed Retrospective Modified Overt Aggression Scale.
Participants included 175 children (mean SD age 9.48 2.04 years, 19% female). Of participants, 151 completed the stimulant optimization phase, with aggression remitting among 96 (63%), and 45 were randomly assigned to adjunctive treatment groups. The adjunctive RISP group showed greater reductions in aggression ratings than the PBO group (least squares means difference ΔLSM, -2.33; 95% CI, -3.83 to -0.82; effect size ES, -1.32), as did the DVPX group (ΔLSM, -1.60; 95% CI, -3.18 to -0.03; ES, -0.91). Mean standardized body mass index scores increased more among RISP-treated participants than participants receiving PBO (ΔLSM, 1.54; 95% CI, 0.68 to 2.40; ES, 0.58).
High response rate during the trial's open stimulant optimization phase suggests that rigorous titration of stimulant medication and concurrent behavioral therapy may avert the need for additional medications. Among nonremitters, RISP and DVPX were efficacious adjunctive treatments, although RISP was associated with weight gain.
Effectiveness of Combined Medication Treatment for Aggression in Children With Attention Deficit With Hyperactivity Disorder (The SPICY Study); https://www.clinicaltrials.gov; NCT00794625.
Stimulant treatment improves impulse control among children with attention-deficit/hyperactivity disorder (ADHD). Decreased aggression often accompanies stimulant pharmacotherapy, suggesting that ...impulsiveness is integral to aggressive behavior in these children. However, children with high callous-unemotional (CU) traits and proactive aggression may benefit less from ADHD pharmacotherapy, because their aggressive behavior seems more purposeful and deliberate. This study's objective was to determine whether pretreatment CU traits and proactive aggression affect treatment outcomes among aggressive children with ADHD receiving stimulant monotherapy.
We implemented a stimulant optimization protocol with 160 children 6 to 13 years of age (mean SD age of 9.31 2.02 years; 78.75% male) with ADHD, oppositional defiant or conduct disorder, and significant aggressive behavior. Family-focused behavioral intervention was provided concurrently. The primary outcome was the Retrospective Modified Overt Aggression Scale. The Antisocial Process Screening Device and the Aggression Scale, also completed by parents, measured CU traits and proactive aggression, respectively. Analyses examined moderating effects of CU traits and proactive aggression on outcomes.
In all, 82 children (51%) experienced remission of aggressive behavior. Neither CU traits nor proactive aggression predicted remission (CU traits: odds ratio OR = 0.94, 95% CI = 0.80-1.11; proactive aggression, OR = 1.05, 95% CI = 0.86-1.29). Children whose overall aggression remitted showed decreases in CU traits (effect size = -0.379, 95% CI = -0.60 to -0.16) and proactive aggression (effect size = -0.463, 95% CI = -0.69 to -0.23).
Findings suggest that pretreatment CU traits and proactive aggression do not forecast worse outcomes for aggressive children with ADHD receiving optimized stimulant pharmacotherapy. With such treatment, CU traits and proactive aggression may decline alongside other behavioral improvements. Clinical trial registration information--Medication Strategies for Treating Aggressive Behavior in Youth With Attention Deficit Hyperactivity Disorder; http://clinicaltrials.gov/; NCT00228046; and Effectiveness of Combined Medication Treatment for Aggression in Children With Attention Deficit With Hyperactivity Disorder (The SPICY Study); http://clinicaltrials.gov/; NCT00794625.
To examine the electrophysiological effects of methylphenidate (MPH) on inhibitory control in children with attention deficit/hyperactivity disorder (ADHD).
Twelve children with ADHD performed the ...Stop Signal Task (SST) while event related potentials (ERP) were obtained. Each child completed two testing sessions, once on placebo and again on an individualized dose of MPH, with the order of medication administration counterbalanced. The following ERP parameters were studied: the N200, often seen as a measure of the activation of the inhibitory process, and the NoGo-P3, which may represent the degree of performance monitoring and/or error detection.
MPH significantly improved behavioral performance on the SST. During successful inhibitions, MPH also significantly increased the amplitude of the right frontal N200, while during unsuccessful inhibitions MPH increased the amplitude of the NoGo-P3.
MPH may improve inhibitory control by enhancing brain mechanisms that trigger the inhibitory process and make stopping a motor act more probable (reflected by increased N200) and by increasing attentional resources to the task when unsuccessful inhibitions occur (as reflected by increased NoGo-P3). These results are consistent with functional imaging studies suggesting a role for the right frontal inferior cortex and the cingulate cortex in the pathophysiology of ADHD.
This article highlights the history of the psychiatric training practices that have contributed to inequity in mental health service delivery, particularly to underserved populations. It discusses ...current training practices that may be effective at reducing such disparities, suggests policy recommendations to increase the number of underrepresented minorities in health services, and makes recommendations for the further development and implementation of training practices that address health inequity. The article reviews issues in both general psychiatry and child/adolescent training in addition to lifelong learning needs.
New and original collection of scholarly essays examining the literary complexities of the Atlantic world system This Companion offers a critical overview of the diverse and dynamic field of Atlantic ...literary studies, with contributions by distinguished scholars on a series of topics that define the area. The essays focus on literature and culture from first contact to the present, exploring fruitful Atlantic connections across space and time, across national cultures, and embracing literature, culture and society. This research collection proposes that the analysis of literature and culture does not depend solely upon geographical setting to uncover textual meaning. Instead, it offers Atlantic connections based around migration, race, gender and sexuality, ecologies, and other significant ideological crossovers in the Atlantic World. The result is an exciting new critical map written by leading international researchers of a lively and expanding field.Key Features
Offers an introduction to the growing field of Atlantic literary studies by showcasing current work engaged in debate around historical, cultural and literary issues in the Atlantic World
Includes 26 newly-commissioned scholarly essays by leading experts in Atlantic literary studies
Fuses breadth of historical knowledge with depth of literary scholarship
Considers the full range of intercultural encounters around and across the Atlantic Ocean This Companion offers a critical overview of the diverse and dynamic field of Atlantic literary studies, with contributions by distinguished scholars on a series of topics that define the area. The essays focus on literature and culture from first contact to the present, exploring fruitful Atlantic connections across space and time, across national cultures, and embracing literature, culture and society. This research collection proposes that the analysis of literature and culture does not depend solely upon geographical setting to uncover textual meaning. Instead, it offers Atlantic connections based around migration, race, gender and sexuality, ecologies, and other significant ideological crossovers in the Atlantic World. The result is an exciting new critical map written by leading international researchers of a lively and expanding field.
PDF
