Cardiovascular Monitoring of Children and Adolescents With Heart Disease Receiving Medications for Attention Deficit/Hyperactivity Disorder
A Scientific Statement From the American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects Committee and the Council on Cardiovascular Nursing.

Vetter VL, Elia J, Erickson C, Berger S, Blum N, Uzark K, Webb CL; American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects Committee; American Heart Association Council on Cardiovascular Nursing.

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Mental Health in the United States: Prevalence of Diagnosis and Medication Treatment for Attention-Deficit/Hyperactivity Disorder–United States, 2003.

Visser SN, Lesesne CA.

Centers for Disease Control and Prevention

FDA Issues Safety Communication about an Ongoing Review of Stimulant Medications Used in Children with ADHD

U.S. Food and Drug Administration

Communication about an Ongoing Safety Review of Stimulant Medications used in Children with Attention-Deficit/Hyperactivity Disorder (ADHD)

U.S. Food and Drug Administration

Clarifying Guidelines on ECG Monitoring for ADHD Children
Several Groups Say Screening for Heart Conditions Is Useful But Not Mandatory.

Low, K.

Pediatric Use of Stimulants Linked to Sudden Death

Neale, T.
Reviewed by Zaleznik, DF. MD.

Antipsychotic Drugs and Sudden Cardiac Death
Both typical and atypical agents doubled risk for sudden cardiac death.

Brett, AS.

How common is attention-deficit/hyperactivity disorder? Incidence in a population-based birth cohort in Rochester, Minn.

Barbaresi WJ, Katusic SK, Colligan RC, Pankratz VS, Weaver AL, Weber KJ, Mrazek DA, Jacobsen SJ.

Division of Developmental and Behavioral Pediatrics, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA. barbaresi.william@mayo.edu

CONTEXT: The frequency of occurrence of attention-deficit/hyperactivity disorder (AD/HD) is in dispute. This uncertainty has contributed to the concern that too many children in the United States are being treated with stimulant medication. OBJECTIVES: To determine the cumulative incidence of AD/HD in a population-based birth cohort and to estimate the prevalence of pharmacologic treatment for children who fulfill research criteria for AD/HD. DESIGN: Population-based birth cohort study. SETTING AND SUBJECTS: All children born between 1976 and 1982 in Rochester, Minn, who remained in the community after age 5 years (N = 5718). MAIN OUTCOME MEASURES: Medical and school records were reviewed for clinical diagnoses of AD/HD and supporting documentation (symptoms consistent with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria and positive results for AD/HD-related questionnaires). Research-identified cases were defined as: (1) "definite" AD/HD (clinical diagnosis and at least one type of supporting documentation); (2) "probable" AD/HD (clinical diagnosis but no supporting documentation or no clinical diagnosis but both types of supporting documentation); (3) "questionable" AD/HD (no clinical diagnosis, but at least one type of supporting documentation); and (4) "not AD/HD" (all other subjects). Information about pharmacologic treatment for AD/HD was abstracted for all subjects. RESULTS: The highest estimate of the cumulative incidence at age 19 years (with 95% confidence interval) of AD/HD (definite plus probable plus questionable AD/HD) was 16.0% (14.7-17.3). The lowest estimate (definite AD/HD only) was 7.4% (6.5-8.4). Prevalence of treatment with stimulant medication was 86.5% for definite AD/HD, 40.0% for probable AD/HD, 6.6% for questionable AD/HD, and 0.2% for not AD/HD. CONCLUSIONS: These results provide insight into the apparent discrepancies in estimates of the occurrence of AD/HD, with less stringent criteria resulting in higher cumulative incidence. Children who met the most stringent criteria for AD/HD were most likely to receive pharmacologic treatment.

Prevalence and assessment of attention-deficit/hyperactivity disorder in primary care settings.

Brown RT, Freeman WS, Perrin JM, Stein MT, Amler RW, Feldman HM, Pierce K, Wolraich ML.

Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA.

Research literature relating to the prevalence of attention-deficit/hyperactivity disorder (ADHD) and co-occurring conditions in children from primary care settings and the general population is reviewed as the basis of the American Academy of Pediatrics clinical practice guideline for the assessment and diagnosis of ADHD. Epidemiologic studies revealed prevalence rates generally ranging from 4% to 12% in the general population of 6 to 12 year olds. Similar or slightly lower rates of ADHD were revealed in pediatric primary care settings. Other behavioral, emotional, and learning problems significantly co-occurred with ADHD. Also reviewed were rating scales and medical tests that could be employed in evaluating ADHD. The utility of using both parent- and teacher-completed rating scales that specifically assess symptoms of ADHD in the diagnostic process was supported. Recommendations were made regarding the assessment of children with suspected ADHD in the pediatric primary care setting.

The epidemiology of attention-deficit/hyperactivity disorder (ADHD): a public health view.

Rowland AS, Lesesne CA, Abramowitz AJ.

MPH Program, Department of Family and Community Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA. arowland@salud.unm.edu

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder of childhood. However, basic information about how the prevalence of ADHD varies by race/ethnicity, sex, age, and socio-economic status remains poorly described. One reason is that difficulties in the diagnosis of ADHD have translated into difficulties developing an adequate case definition for epidemiologic studies. Diagnosis depends heavily on parent and teacher reports; no laboratory tests reliably predict ADHD. Prevalence estimates of ADHD are sensitive to who is asked what, and how information is combined. Consequently, recent systematic reviews report ADHD prevalence estimates as wide as 2%-18%. The diagnosis of ADHD is complicated by the frequent occurrence of comorbid conditions such as learning disability, conduct disorder, and anxiety disorder. Symptoms of these conditions may also mimic ADHD. Nevertheless, we suggest that developing an adequate epidemiologic case definition based on current diagnostic criteria is possible and is a prerequisite for further developing the epidemiology of ADHD. The etiology of ADHD is not known but recent studies suggest both a strong genetic link as well as environmental factors such as history of preterm delivery and perhaps, maternal smoking during pregnancy. Children and teenagers with ADHD use health and mental health services more often than their peers and engage in more health threatening behaviors such as smoking, and alcohol and substance abuse. Better methods are needed for monitoring the prevalence and understanding the public health implications of ADHD. Stimulant medication is the treatment of choice for treating ADHD but psychosocial interventions may also be warranted if comordid disorders are present. The treatment of ADHD is controversial because of the high prevalence of medication treatment. Epidemiologic studies could clarify whether the patterns of ADHD diagnosis and treatment in community settings is appropriate. Population-based epidemiologic studies may shed important new light on how we understand ADHD, its natural history, its treatment and its consequences. Copyright 2002 Wiley-Liss, Inc.

Short-term cardiovascular effects of methylphenidate and adderall.

Findling RL, Short EJ, Manos MJ.

Department of Psychiatry and Pediatrics, University Hospitals of Cleveland, Case Western Reserve University, OH 44106-5080, USA.

OBJECTIVE: The primary purpose of this study was to examine the cardiovascular effects of Adderall (ADL) in a clinic-based group of youths with attention-deficit/hyperactivity disorder ranging in age from 4 to 17 years. METHOD: One hundred thirty-seven patients were treated with either methylphenidate (MPH) or ADL. Youths prescribed MPH were given medication twice daily, and youths treated with ADL received medication once daily. Patients were evaluated under five conditions: baseline, placebo, 5 mg/dose, 10 mg/dose, or 15 mg/dose. Resting pulse, diastolic blood pressure, and systolic blood pressure were examined after 1 week at each treatment condition. Changes from baseline on these parameters were examined. RESULTS: The short-term cardiovascular effects of both ADL and MPH were modest. No patients experienced any clinically significant change in these cardiovascular measures during the course of this brief trial. CONCLUSION: Since the short-term cardiovascular effects of ADL appear minimal, specific cardiovascular monitoring during short-term ADL treatment at doses of 15 mg/day or less does not appear to be indicated. In addition, under similar conditions, using similar methods, both medication treatments led to changes in blood pressure and pulse that were clinically insignificant.

Effect of stimulants on 24-h ambulatory blood pressure in children with ADHD: a double-blind, randomized, cross-over trial.

Samuels JA, Franco K, Wan F, Sorof JM.

Pediatric Nephrology and Hypertension, The University of Texas Health Science Center at Houston, USA.

Millions of children with attention deficit hyperactivity disorder (ADHD) are treated with stimulant medications. To evaluate cardiovascular risk, 24-h ambulatory blood pressure monitoring (ABPM) was performed on and off medication. Thirteen subjects underwent APBM both on stimulant therapy and placebo using a placebo-controlled, double-blind, randomized, cross-over design. After a 3-day run-in followed by a 24-h monitoring period, subjects crossed over to the alternate therapy for repeated ABPM. Subjects demonstrated elevations in most hemodynamic parameters derived from ABPM during the active treatment period. Total diastolic blood pressure (69.7 mmHg vs 65.8 mmHg, p =0.02) and waking diastolic blood pressure (75.5 mmHg vs 72.3 mmHg, p =0.03) were significantly higher during active treatment. Total heart rate was also significantly higher during active treatment (85.5 beats/min vs 79.9 beats/min, p =0.004). The rate-pressure product (the product of systolic blood pressure x heart rate), an index of myocardial oxygen demand, was higher during active treatment (9,958 vs 9,076, p =0.008). This study provides evidence for a possible negative cardiovascular effect of stimulant medications in children with ADHD. This potential cardiovascular risk should be balanced against the beneficial behavioral effects of this class of medication.

Cost effectiveness analysis of screening of high school athletes for risk of sudden cardiac death.

Fuller CM.

Sierra Nevada Cardiology Associates and Sierra Heart Institute, Reno, NV 89502, USA. RFuller007@aol.com

Sudden cardiac death of a high school athlete is an alarming tragedy. Three preparticipation screening methods have been recommended to reduce its occurrence: specific cardiovascular history and physical examination, 12-lead ECG, and two-dimensional (2D) echocardiography. This study analyzes the cost effectiveness of each of these methods. The cost to perform each test and to evaluate abnormal screening findings were approximated. The years of life gained through detection of athletes with potential causes of sudden cardiac death were estimated. Overall, the approximate costs per year of life saved for the preparticipation cardiovascular screening examinations are: specific cardiovascular history and physical examination, $84,000; 12-lead ECG, $44,000; and 2D echocardiography, $200,000. The 12-lead ECG is the most cost effective preparticipation cardiovascular modality of the three currently recommended methods. Similar cost effectiveness for history and physical examination or 2D echocardiography would require respectively a 2-fold increase in sensitivity or 4.5-fold decrease in cost.