November 2, 2023
While influenza normally only threatens the elderly or those with complicating conditions, the 2009 H1N1 variant struck children particularly hard.
ADHD is known to be associated with inflammatory and immune-related disorders such as asthma, eczema, and allergic rhinitis. These disorders can aggravate respiratory infections such as influenza. Moreover, the cognitive deficits characteristic of ADHD - difficulty following instructions, reduced ability to control impulsive behavior and resulting nail-biting, and poor hand hygiene - can increase the probability of infection in the first place.
A Taiwanese research team explored how drug treatment for ADHD might affect the risk of childhood influenza. Only two drugs are approved in Taiwan for treating ADHD: the stimulant methylphenidate (MPH) and the non-stimulant atomoxetine. Because the latter is only recommended for patients who have unsatisfactory outcomes with MPH, MPH is the drug used in the vast majority of cases.
Taiwan is one of the relatively few countries that track the health care of its entire population in a comprehensive database, thanks to a single-payer health care system launched in1995. From the National Health Insurance Research Database, the Bureau of National Health Insurance in 2005 used random sampling to create a million-person Longitudinal Health Insurance Database (roughly five percent of the population).
From this latter database, the research team identified 9,826 patients newly diagnosed with ADHD. They excluded 1,786 with influenza before their ADHD diagnosis. After further excluding those outside the youth age brackets or who had gotten a flu shot during the year preceding enrollment, they were left with 5,259 patients with ADHD under age 18. Of these, 661 got influenza following diagnosis of ADHD.
In this ADHD cohort, 43 percent had not used any medication. Of the 57% who used medication, 20 percent did so for 90 days or less, and 37 percent for over 90 days.
After controlling for gender, age, level of urbanization, psychiatric or physical illnesses, and other medication use(sedative/hypnotics/anxiolytics), those prescribed MPH over 90 days were 38 percent less likely to get influenza requiring interaction with the health care system. There was a lesser reduction for those taking MPH 90 days or less, but it was not statistically significant.
A significant limitation is the fact that data from in-school vaccination programs are not included in the database used. If children receiving less or no medication were also less likely to be vaccinated, this unexplored covariate could explain the results. Further study is needed.
Hsuan Lee, VincentChin-Hung Chen, Yao-Hsu Yang , Ting-Yu Kuo, Tzu-Chin Lin, Shu-I Wu, Kai-LiangKao, Jun-Cheng Weng, Brent Allan Kelsen, Sophie Hsin-Yi Liang, "Decreased Risk of Influenza in Child and Adolescent Patients with Attention-Deficit Hyperactivity DisorderFollowing Methylphenidate Treatment: A Nationwide Cohort Study in Taiwan," NeuropsychiatricDisease and Treatment (2020), 16: 1309-1319, https://doi.org/10.2147/NDT.S242519.
A new large-scale study has shed light on which treatments for attention-deficit/hyperactivity disorder (ADHD) in adults are most effective and best tolerated.
Researchers analyzed 113 randomized controlled trials involving nearly 15,000 adults diagnosed with ADHD. These studies included medications (like stimulants and atomoxetine), psychological therapies (such as cognitive behavioral therapy), and newer approaches like neurostimulation.
The Findings
Stimulant medications (lisdexamfetamine and methylphenidate) as well as selective norepinephrine reuptake inhibitors (SNRI) (atomoxetine) were the only treatments that consistently reduced core ADHD symptoms—both from the perspective of patients and clinicians. It may be worth noting that atomoxetine, while effective, was less well tolerated, with more people dropping out due to side effects.
Psychological therapies such as CBT, mindfulness, and psychoeducation showed some benefits, but mainly according to clinician ratings—not necessarily from the patients themselves. Neurostimulation techniques like transcranial direct current stimulation also showed some improvements, but only in limited contexts and with small sample sizes. Interestingly, none of the treatments—medication or otherwise—made a clear impact on long-term quality of life or emotional regulation.
Conclusion
So, what does this mean for people navigating ADHD in adulthood? Stimulant medications remain the most effective treatment for managing ADHD symptoms day-to-day but nonstimulant medication are not far behind, which is good given the problems we’ve had with stimulant shortages. This study also supports structured psychotherapy as a viable treatment option, especially when used in conjunction with medication.
The study emphasizes the importance of ongoing, long-term research and the need for treatment plans that are tailored to the individual ADHD patient– Managing adult ADHD effectively calls for flexible, patient-centered care.
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Precocious puberty (PP) is defined as the onset of secondary sex characteristics before age 8 in girls or age 9 in boys.
Because it accelerates skeletal maturation by prematurely shutting down the cartilage growth plate at the tip of long bones, it tends to lead to shorter height in adulthood. It is also known to place an additional psychological burden on children, especially girls. Girls are four to 38 times more likely to develop PP than boys.
Taiwan has a single-payer national health insurance system, called National Health Insurance, that encompasses 99.6% of the island’s population. The Ministry of Health and Welfare uses it to maintain the National Health Insurance Research Database (NHIRD), enabling researchers to conduct nationwide population studies.
Using this database, a Taiwanese study team investigated the relationship between ADHD and precocious puberty among children and adolescents (under 18). And because methylphenidate (MPH) is the only psychostimulant approved for the treatment of ADHD in Taiwan, the team also explored the effect of MPH on this relationship.
Most diagnoses of ADHD in the NHIRD are made by board-certified psychiatrists, enhancing diagnostic validity.
Of the more than 3.3 million persons born in Taiwan between 1997 and 2001, 186,681 were diagnosed with ADHD. Of these, 122,302 were prescribed MPH.
After adjusting for sex, low-income households, and neuropsychiatric comorbidities, children diagnosed with ADHD were twice as likely to be diagnosed with PP. This held equally true for boys and girls.
However, children diagnosed with ADHD and prescribed MPH were more than a third less likely to subsequently be diagnosed with PP than those diagnosed with ADHD but not prescribed MPH.
For girls with ADHD, who without an MPH prescription were nine times more likely than boys with ADHD to be diagnosed with PP, an MPH prescription reduced that ratio to five times more likely than boys with ADHD and prescribed MPH.
That suggests a strong protective effect of MPH.
The team concluded, “Our study found that children with ADHD were at a greater risk of PP, and girls with ADHD were a particularly vulnerable group. … MPH appeared to be protective against PP in patients with ADHD, especially in girls. However, these preliminary results need further validation.”
Maternal infections and inflammatory responses during pregnancy have been proposed as risk factors for neurodevelopmental disorders such as ADHD.
Taiwan has a single-payer health insurance system that covers virtually the entirety of its population. Its Ministry of Health and Welfare maintains the National Health Insurance Research Database (NHIRD), with detailed information on outpatient services, hospitalizations, and medical treatment for nearly 99% of all residents.
A Taiwanese study team used NHIRD to examine to examine the relationship between maternal hospitalization for infection, and early childhood infection, and subsequent ADHD in offspring. The study cohort originated with all 3,260,879 individuals born between 2001 and 2018.
The team excluded births from foreign mothers, still births, births with congenital defects, low birth weights, abnormally late births, twins, triplets, and other multiple births, culminating in a final population cohort of 2,885,662 live-born single infants across 1,893,171 families, and 1,864,660 individuals with full siblings from 872,169 families comprising the full sibling cohort.
Study participants were followed until diagnosis of a neurodevelopmental disorder, their death, or the end of 2021.
After adjusting for sex, birth year, paternal and maternal ages, birthweight, birth season, parity, delivery method, 1 minute APGAR score (evaluating baby’s appearance, pulse, grimace, activity and respiration at birth), gestational age, pregnancy and delivery complications, parental history of neurodevelopmental disorders, maternal asthma and diabetes, urbanization level of the residential area, and family’s insurance amount, offspring of mothers hospitalized for infections had 14% greater odds of being subsequently diagnosed with ADHD.
However, in the full sibling cohort of over 1.8 million, this association vanished. That held true for each of the three trimesters of pregnancy. It also held true for bacterial infections. Surprisingly, offspring of mothers hospitalized for viral infections were 24% less likely to be diagnosed with ADHD than their siblings not exposed to maternal viral infection. Because of that, they also had a 6% lower risk overall.
After the same adjustments, early childhood infection was associated with 16% greater odds of being diagnosed with ADHD.
Nevertheless, in the full sibling cohort of over 1.8 million, this association again vanished. That held true overall, as well as separately for childhood infections in months 1-6 and months 7-12. The association vanished altogether both for bacterial infections as well as for viral infections.
The authors concluded, “the results of this nationwide birth cohort study with population and sibling analyses suggest that the association between maternal infection during pregnancy and offspring neurodevelopmental risk is largely due to familial confounding factors.”
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