ADHD

Exposure to deprivation in early life was significantly associated with impaired executive functioning in children and adolescents, based on data from a systematic review and meta-analysis of 91 studies.

Previous research has shown connections between early-life adversity (ELA) and changes in psychological, cognitive, and neurobiological development, including increased risk of anxiety, depression, attention-deficit/hyperactivity disorder, conduct disorder, suicidality, and substance use disorder; however, research focusing on the associations between different types of ELA and specific processes is limited, wrote Dylan Johnson, MSc, of the University of Toronto and colleagues.

“We directly addressed this gap in the literature by examining the association between the type of ELA and executive functioning in children and youth,” they said.

In a study published in JAMA Pediatrics, the researchers identified 91 articles including 82 unique cohorts and 31,188 unique individuals aged 1-18 years.

The articles were selected from Embase, ERIC, MEDLINE, and PsycInfo databases and published up to Dec. 31, 2020. The primary outcomes were measures of the three domains of executive functioning: cognitive flexibility, inhibitory control, and working memory. To correct for small sample sizes in some studies, the researchers standardized their measures of association into Hedges g effect sizes.

Overall, the pooled estimates of the association of any childhood adversity with the three domains of executive functioning showed significant heterogeneity, with Hedges g effects of –0.49 for cognitive flexibility, –0.39 for inhibitory control, and –0.47 for working memory.

The researchers also examined a subsample of ELA–executive functioning associations in categories of early-life exposure to threat, compared with early-life deprivation, including 56 of the original 91 articles. In this analysis, significantly lower inhibitory control was associated with deprivation compared to threat (Hedges g –0.43 vs. –0.27). Similarly, significantly lower working memory was associated with deprivation, compared with threat (Hedges g –0.54 vs. Hedges g –0.28). For both inhibitory control and working memory, the association of adversity was not moderated by the age or sex of the study participants, study design, outcome quality, or selection quality, the researchers noted.

No significant difference in affect of exposure threat vs. deprivation was noted for the association with cognitive flexibility. The reason for this discrepancy remains unclear, the researchers said. “Some evidence suggests that individuals who grow up in unpredictable environments may have reduced inhibitory control but enhanced cognitive flexibility,” they noted.

However, the overall results suggest that exposure to deprivation may be associated with neurodevelopmental changes that support the development of executive functioning, they said.

The study findings were limited by several factors, including the substantial heterogeneity in the pooled estimates and the need to consider variation in study design, the researchers noted. In addition, the cross-sectional design of many studies prevented conclusions about causality between ELA and executive functioning, they said.

“Future research should explore the differences between threat and deprivation when emotionally salient executive functioning measures are used,” the researchers emphasized. “Threat experiences are often associated with alterations in emotional processing, and different findings may be observed when investigating emotionally salient executive functioning outcomes,” they concluded.
 

Prevention and intervention plans needed

“Although numerous studies have examined associations between ELA and executive functioning, the associations of threat and deprivation with specific executive functioning domains (e.g., cognitive flexibility, inhibitory control, and working memory) have not been explored comprehensively,” wrote Beth S. Slomine, PhD, and Nikeea Copeland-Linder, PhD, of the Kennedy Krieger Institute, Johns Hopkins University School, Baltimore, in an accompanying editorial.

The study is “critical and timely” because of the impact of the COVID-19 pandemic on children’s exposure to deprivation, the authors said. “Many children have experienced the death of family members or friends, food and housing insecurity owing to the economic recession, school closures, loss of critical support services, and increased isolation because of social distancing measures,” and these effects are even greater for children already living in poverty and those with developmental disabilities, they noted.

More resources are needed to develop and implement ELA prevention policies, as well as early intervention plans, the editorialists said.

“Early intervention programs have a great potential to reduce the risk of ELA and promote executive functioning development,” they said. “These programs, such as family support and preschool services, are viable solutions for children and their families,” they added. Although the pandemic prevented the use of many support services for children at risk, the adoption of telehealth technology means that “it is now more feasible for cognitive rehabilitation experts to implement the telehealth technology to train parents and school staff on how to assist with the delivery of interventions in real-world settings and how to promote executive functioning in daily life,” they noted.

Overall, the study findings highlight the urgency of identifying ELA and implementing strategies to reduce and prevent ELA, and to provide early intervention to mitigate the impact of ELA on executive function in children, the editorialists emphasized.
 

Data bring understanding, but barriers remain

“At this point, there are data demonstrating the significant impact that adverse childhood experiences have on health outcomes – from worsened mental health to an increased risk for cancer and diabetes,” said Kelly A. Curran, MD, of the University of Oklahoma Health Sciences Center, Oklahoma City, in an interview.

“Physicians – myself included – tend to lump all these experiences together when thinking about future health outcomes,” Dr. Curran said. “However, there are evolving data that neurocognitive outcomes may be different based on the type of early-life adversity experienced. This meta-analysis examines the risk of different neurocognitive impact of threat versus deprivation types of adversity, which is important to pediatricians because it helps us to better understand the risks that our patients may experience,” she explained. 

“The results of this meta-analysis were especially intriguing because I hadn’t previously considered the impact that different types of adversity had on neurocognitive development,” said Dr. Curran. “This study caused me to think about these experiences differently, and as I reflect on the patients I have cared for over the years, I can see the difference in their outcomes,” she said.

Many barriers persist in addressing the effects of early-life deprivation on executive function, Dr. Curran said.

“First are barriers around identification of these children and adolescents, who may not have regular contact with the medical system. Additionally, it’s important to provide resources for parents and caregivers – this includes creating a strong support network and providing education about the impact of these experiences,” she noted. “There are also barriers to identifying and connecting with what resources will help children at risk of poor neurodevelopmental outcomes,” she added.

“Now that we know that children who have experienced early-life deprivation are at increased risk of worsened neurodevelopmental outcomes, it will be important to understand what interventions can help improve their outcomes,” Dr. Curran said.

The study was supported by a Connaught New Researcher Award from the University of Toronto. The researchers had no financial conflicts to disclose.

Dr. Slomine disclosed book royalties from Cambridge University Press unrelated to this study. Dr. Curran had no financial conflicts to disclose, but serves on the Pediatric News Editorial Advisory Board.

Exposure to deprivation in early life was significantly associated with impaired executive functioning in children and adolescents, based on data from a systematic review and meta-analysis of 91 studies.

Previous research has shown connections between early-life adversity (ELA) and changes in psychological, cognitive, and neurobiological development, including increased risk of anxiety, depression, attention-deficit/hyperactivity disorder, conduct disorder, suicidality, and substance use disorder; however, research focusing on the associations between different types of ELA and specific processes is limited, wrote Dylan Johnson, MSc, of the University of Toronto and colleagues.

“We directly addressed this gap in the literature by examining the association between the type of ELA and executive functioning in children and youth,” they said.

In a study published in JAMA Pediatrics, the researchers identified 91 articles including 82 unique cohorts and 31,188 unique individuals aged 1-18 years.

The articles were selected from Embase, ERIC, MEDLINE, and PsycInfo databases and published up to Dec. 31, 2020. The primary outcomes were measures of the three domains of executive functioning: cognitive flexibility, inhibitory control, and working memory. To correct for small sample sizes in some studies, the researchers standardized their measures of association into Hedges g effect sizes.

Overall, the pooled estimates of the association of any childhood adversity with the three domains of executive functioning showed significant heterogeneity, with Hedges g effects of –0.49 for cognitive flexibility, –0.39 for inhibitory control, and –0.47 for working memory.

The researchers also examined a subsample of ELA–executive functioning associations in categories of early-life exposure to threat, compared with early-life deprivation, including 56 of the original 91 articles. In this analysis, significantly lower inhibitory control was associated with deprivation compared to threat (Hedges g –0.43 vs. –0.27). Similarly, significantly lower working memory was associated with deprivation, compared with threat (Hedges g –0.54 vs. Hedges g –0.28). For both inhibitory control and working memory, the association of adversity was not moderated by the age or sex of the study participants, study design, outcome quality, or selection quality, the researchers noted.

No significant difference in affect of exposure threat vs. deprivation was noted for the association with cognitive flexibility. The reason for this discrepancy remains unclear, the researchers said. “Some evidence suggests that individuals who grow up in unpredictable environments may have reduced inhibitory control but enhanced cognitive flexibility,” they noted.

However, the overall results suggest that exposure to deprivation may be associated with neurodevelopmental changes that support the development of executive functioning, they said.

The study findings were limited by several factors, including the substantial heterogeneity in the pooled estimates and the need to consider variation in study design, the researchers noted. In addition, the cross-sectional design of many studies prevented conclusions about causality between ELA and executive functioning, they said.

“Future research should explore the differences between threat and deprivation when emotionally salient executive functioning measures are used,” the researchers emphasized. “Threat experiences are often associated with alterations in emotional processing, and different findings may be observed when investigating emotionally salient executive functioning outcomes,” they concluded.
 

Prevention and intervention plans needed

“Although numerous studies have examined associations between ELA and executive functioning, the associations of threat and deprivation with specific executive functioning domains (e.g., cognitive flexibility, inhibitory control, and working memory) have not been explored comprehensively,” wrote Beth S. Slomine, PhD, and Nikeea Copeland-Linder, PhD, of the Kennedy Krieger Institute, Johns Hopkins University School, Baltimore, in an accompanying editorial.

The study is “critical and timely” because of the impact of the COVID-19 pandemic on children’s exposure to deprivation, the authors said. “Many children have experienced the death of family members or friends, food and housing insecurity owing to the economic recession, school closures, loss of critical support services, and increased isolation because of social distancing measures,” and these effects are even greater for children already living in poverty and those with developmental disabilities, they noted.

More resources are needed to develop and implement ELA prevention policies, as well as early intervention plans, the editorialists said.

“Early intervention programs have a great potential to reduce the risk of ELA and promote executive functioning development,” they said. “These programs, such as family support and preschool services, are viable solutions for children and their families,” they added. Although the pandemic prevented the use of many support services for children at risk, the adoption of telehealth technology means that “it is now more feasible for cognitive rehabilitation experts to implement the telehealth technology to train parents and school staff on how to assist with the delivery of interventions in real-world settings and how to promote executive functioning in daily life,” they noted.

Overall, the study findings highlight the urgency of identifying ELA and implementing strategies to reduce and prevent ELA, and to provide early intervention to mitigate the impact of ELA on executive function in children, the editorialists emphasized.
 

Data bring understanding, but barriers remain

“At this point, there are data demonstrating the significant impact that adverse childhood experiences have on health outcomes – from worsened mental health to an increased risk for cancer and diabetes,” said Kelly A. Curran, MD, of the University of Oklahoma Health Sciences Center, Oklahoma City, in an interview.

“Physicians – myself included – tend to lump all these experiences together when thinking about future health outcomes,” Dr. Curran said. “However, there are evolving data that neurocognitive outcomes may be different based on the type of early-life adversity experienced. This meta-analysis examines the risk of different neurocognitive impact of threat versus deprivation types of adversity, which is important to pediatricians because it helps us to better understand the risks that our patients may experience,” she explained. 

“The results of this meta-analysis were especially intriguing because I hadn’t previously considered the impact that different types of adversity had on neurocognitive development,” said Dr. Curran. “This study caused me to think about these experiences differently, and as I reflect on the patients I have cared for over the years, I can see the difference in their outcomes,” she said.

Many barriers persist in addressing the effects of early-life deprivation on executive function, Dr. Curran said.

“First are barriers around identification of these children and adolescents, who may not have regular contact with the medical system. Additionally, it’s important to provide resources for parents and caregivers – this includes creating a strong support network and providing education about the impact of these experiences,” she noted. “There are also barriers to identifying and connecting with what resources will help children at risk of poor neurodevelopmental outcomes,” she added.

“Now that we know that children who have experienced early-life deprivation are at increased risk of worsened neurodevelopmental outcomes, it will be important to understand what interventions can help improve their outcomes,” Dr. Curran said.

The study was supported by a Connaught New Researcher Award from the University of Toronto. The researchers had no financial conflicts to disclose.

Dr. Slomine disclosed book royalties from Cambridge University Press unrelated to this study. Dr. Curran had no financial conflicts to disclose, but serves on the Pediatric News Editorial Advisory Board.

Exposure to deprivation in early life was significantly associated with impaired executive functioning in children and adolescents, based on data from a systematic review and meta-analysis of 91 studies.

Previous research has shown connections between early-life adversity (ELA) and changes in psychological, cognitive, and neurobiological development, including increased risk of anxiety, depression, attention-deficit/hyperactivity disorder, conduct disorder, suicidality, and substance use disorder; however, research focusing on the associations between different types of ELA and specific processes is limited, wrote Dylan Johnson, MSc, of the University of Toronto and colleagues.

“We directly addressed this gap in the literature by examining the association between the type of ELA and executive functioning in children and youth,” they said.

In a study published in JAMA Pediatrics, the researchers identified 91 articles including 82 unique cohorts and 31,188 unique individuals aged 1-18 years.

The articles were selected from Embase, ERIC, MEDLINE, and PsycInfo databases and published up to Dec. 31, 2020. The primary outcomes were measures of the three domains of executive functioning: cognitive flexibility, inhibitory control, and working memory. To correct for small sample sizes in some studies, the researchers standardized their measures of association into Hedges g effect sizes.

Overall, the pooled estimates of the association of any childhood adversity with the three domains of executive functioning showed significant heterogeneity, with Hedges g effects of –0.49 for cognitive flexibility, –0.39 for inhibitory control, and –0.47 for working memory.

The researchers also examined a subsample of ELA–executive functioning associations in categories of early-life exposure to threat, compared with early-life deprivation, including 56 of the original 91 articles. In this analysis, significantly lower inhibitory control was associated with deprivation compared to threat (Hedges g –0.43 vs. –0.27). Similarly, significantly lower working memory was associated with deprivation, compared with threat (Hedges g –0.54 vs. Hedges g –0.28). For both inhibitory control and working memory, the association of adversity was not moderated by the age or sex of the study participants, study design, outcome quality, or selection quality, the researchers noted.

No significant difference in affect of exposure threat vs. deprivation was noted for the association with cognitive flexibility. The reason for this discrepancy remains unclear, the researchers said. “Some evidence suggests that individuals who grow up in unpredictable environments may have reduced inhibitory control but enhanced cognitive flexibility,” they noted.

However, the overall results suggest that exposure to deprivation may be associated with neurodevelopmental changes that support the development of executive functioning, they said.

The study findings were limited by several factors, including the substantial heterogeneity in the pooled estimates and the need to consider variation in study design, the researchers noted. In addition, the cross-sectional design of many studies prevented conclusions about causality between ELA and executive functioning, they said.

“Future research should explore the differences between threat and deprivation when emotionally salient executive functioning measures are used,” the researchers emphasized. “Threat experiences are often associated with alterations in emotional processing, and different findings may be observed when investigating emotionally salient executive functioning outcomes,” they concluded.
 

Prevention and intervention plans needed

“Although numerous studies have examined associations between ELA and executive functioning, the associations of threat and deprivation with specific executive functioning domains (e.g., cognitive flexibility, inhibitory control, and working memory) have not been explored comprehensively,” wrote Beth S. Slomine, PhD, and Nikeea Copeland-Linder, PhD, of the Kennedy Krieger Institute, Johns Hopkins University School, Baltimore, in an accompanying editorial.

The study is “critical and timely” because of the impact of the COVID-19 pandemic on children’s exposure to deprivation, the authors said. “Many children have experienced the death of family members or friends, food and housing insecurity owing to the economic recession, school closures, loss of critical support services, and increased isolation because of social distancing measures,” and these effects are even greater for children already living in poverty and those with developmental disabilities, they noted.

More resources are needed to develop and implement ELA prevention policies, as well as early intervention plans, the editorialists said.

“Early intervention programs have a great potential to reduce the risk of ELA and promote executive functioning development,” they said. “These programs, such as family support and preschool services, are viable solutions for children and their families,” they added. Although the pandemic prevented the use of many support services for children at risk, the adoption of telehealth technology means that “it is now more feasible for cognitive rehabilitation experts to implement the telehealth technology to train parents and school staff on how to assist with the delivery of interventions in real-world settings and how to promote executive functioning in daily life,” they noted.

Overall, the study findings highlight the urgency of identifying ELA and implementing strategies to reduce and prevent ELA, and to provide early intervention to mitigate the impact of ELA on executive function in children, the editorialists emphasized.
 

Data bring understanding, but barriers remain

“At this point, there are data demonstrating the significant impact that adverse childhood experiences have on health outcomes – from worsened mental health to an increased risk for cancer and diabetes,” said Kelly A. Curran, MD, of the University of Oklahoma Health Sciences Center, Oklahoma City, in an interview.

“Physicians – myself included – tend to lump all these experiences together when thinking about future health outcomes,” Dr. Curran said. “However, there are evolving data that neurocognitive outcomes may be different based on the type of early-life adversity experienced. This meta-analysis examines the risk of different neurocognitive impact of threat versus deprivation types of adversity, which is important to pediatricians because it helps us to better understand the risks that our patients may experience,” she explained. 

“The results of this meta-analysis were especially intriguing because I hadn’t previously considered the impact that different types of adversity had on neurocognitive development,” said Dr. Curran. “This study caused me to think about these experiences differently, and as I reflect on the patients I have cared for over the years, I can see the difference in their outcomes,” she said.

Many barriers persist in addressing the effects of early-life deprivation on executive function, Dr. Curran said.

“First are barriers around identification of these children and adolescents, who may not have regular contact with the medical system. Additionally, it’s important to provide resources for parents and caregivers – this includes creating a strong support network and providing education about the impact of these experiences,” she noted. “There are also barriers to identifying and connecting with what resources will help children at risk of poor neurodevelopmental outcomes,” she added.

“Now that we know that children who have experienced early-life deprivation are at increased risk of worsened neurodevelopmental outcomes, it will be important to understand what interventions can help improve their outcomes,” Dr. Curran said.

The study was supported by a Connaught New Researcher Award from the University of Toronto. The researchers had no financial conflicts to disclose.

Dr. Slomine disclosed book royalties from Cambridge University Press unrelated to this study. Dr. Curran had no financial conflicts to disclose, but serves on the Pediatric News Editorial Advisory Board.

In combing the genome, scientists can use genetic clues to determine a person’s risk for psychiatric disease and even identify new drug targets. But the benefits of these discoveries will be limited to people of European descent.

Nearly 90% of participants in genome-wide association studies (GWASs), which search for gene variants linked to disease, are of European ancestry. This Eurocentric focus threatens to widen existing disparities in racial and ethnic mental health.

The significant downsides of genomics’ one-track mind

One obstacle hindering therapeutic advances in psychiatry is a shallow understanding of the mechanisms of disorders. “The biggest problem in terms of advancing research for mental health conditions is that we don’t understand the underlying biology,” says Laramie Duncan, PhD, assistant professor of psychiatry and behavioral sciences at Stanford (Calif.) University. “Genetics is one of the best ways to systematically look for new clues about the underlying biology.”

At the advent of genomic research, scientists thought it best to study DNA from people of a single ancestry from one continent. “Researchers for a long time held the idea that it was going to be too complicated to include multiple ancestries in the first rounds of genetic analyses,” says Dr. Duncan.

Studying DNA from someone with ancestors from multiple parts of the world wasn’t compatible with methods used in the early days of GWASs. “Individual parts of a person’s DNA can be linked back to one region of the world or another, and most of our methods essentially assume that all of a person’s DNA came from one region of the world,” says Dr. Duncan.

Because many genes are usually involved in psychiatric disorders, scientists need large numbers of participants to detect uncommon, influential variants. Early research was concentrated in North America and Europe so that scientists could readily collect samples from people of European ancestry.

“It then went out of hand because it became routine practice to use only this one group, essentially White, European ancestry people,” says Karoline Kuchenbaecker, PhD, associate professor of psychiatry at University College London.

Yet findings from one population won’t necessarily translate to others. “And that’s exactly what has been shown,” says Dr. Teferra. Polygenic risk scores developed for schizophrenia from European samples, for example, perform poorly among people of African ancestry, although among Europeans, they are strongly effective at differentiating European individuals with and those without schizophrenia. Moreover, drugs that target a gene identified from studies in European populations may be harmful to other groups.

Studies drawn from a diverse pool of participants would benefit a wider swath of humanity. They would also allow scientists to discover small areas of overlap in genomes of different populations, which would help them close in on the true biology of diseases and ensure that “we’re all benefiting from more diverse data in genetics and psychiatric genetics,” says Dr. Kuchenbaecker.
 

New efforts aim at filling the gaps

Genomic studies are featuring more people of non-European ancestry, but most of that improvement comes from populations of Asian ancestry, not African, Latin American, or Indigenous ancestry.

Efforts to increase representation of persons of African ancestry have largely focused on African Americans; fewer efforts have extended to the African continent, home to the most genetically diverse populations. Even fewer have focused on mental health. “The little that was being done was on a very small scale,” says Karestan Koenen, PhD, a professor at Harvard School of Public Health, Boston.

With this in mind, researchers from institutions in Kenya, Uganda, South Africa, and Ethiopia partnered with researchers at the Broad Institute of the Massachusetts Institute of Technology and Harvard to conduct the largest GWAS of psychiatric disorders in Africa. Dr. Koenen leads the project, Neuropsychiatric Genetics of African Populations–Psychosis (NeuroGAP-Psychosis), which will analyze DNA from over 35,000 people of African ancestry in each of these four countries. Investigators will compare the half of participants who have no history of psychosis with the half with schizophrenia or bipolar disorder in the hopes of identifying the genetic determinants of psychosis.

“Then any potential intervention or therapeutics that will be developed will also be useful for Africans,” says Dr. Teferra, a NeuroGAP principal investigator. Because of the tremendous degree of genetic diversity among people on the continent, however, findings still might not translate to all African populations.

But correcting equity problems in genomics isn’t as simple as recruiting people with non-European backgrounds, especially if those people are unfamiliar with research or have been subject to scientific exploitation. “Special care needs to be taken to, first of all, provide information that’s appropriate [to participants], but also motivate people to take part and then find ways to keep these communities involved and understand what they’re interested in,” says Dr. Kuchenbaecker, who is not involved with NeuroGAP.

For NeuroGAP, the team needed to work with ethical committees at all of the institutions involved, ensure research materials were appropriate for each community’s cultural context, and gain the trust of local communities.

“One of the biggest criticisms within the scientific world is that people from more endowed countries just fly in, bully everyone, collect the data, and leave, with no credit to the local scientists or communities,” says NeuroGAP principal investigator Lukoye Atwoli, MMed, PhD, professor of psychiatry and dean of the Medical College, East Africa, at the Aga Khan University, Nairobi, Kenya. “That is one of the biggest pitfalls we had to grapple with.”

To address that concern, NeuroGAP is training local researchers and is providing them with requested resources so they can carry out similar studies in the future. “We will be looking to address a real need in the academic community and in clinical service delivery,” says Dr. Atwoli.

Dr. Kuchenbaecker says that NeuroGAP demonstrates features necessary for projects seeking to improve equity in psychiatric genomics. “What they’re doing right is recruiting really large numbers, recruiting from different African countries, and involving African investigators,” she says.

In the Americas, Janitza Montalvo-Ortiz, PhD, assistant professor in the Division of Genetics, department of psychiatry, Yale University, New Haven, Conn., and her colleagues are expanding psychiatric genomics projects in Latin America. She co-founded the Latin American Genomics Consortium in 2019, a network of scientists supporting psychiatric genomic research in the region. The consortium also involves the Neuropsychiatric Genetics in Mexican Populations project, which is similar to NeuroGAP and is also led by Dr. Koenan.

The study of Latin American populations is complicated, because genes in these populations reflect Indigenous American, European, and African ancestries. Even when investigators sampled DNA from Latin American individuals, that data often went unused. “Now with new methods emerging to allow us to properly analyze admixed populations in GWAS studies, we’re making efforts to compile different datasets scattered across different large-scale cohorts,” says Dr. Montalvo-Ortiz. “Our ultimate goal is to conduct the first large-scale LatinX GWAS of psychiatry,” she says.

With these projects, researchers hope that new psychiatric research will produce clinical advances for people historically left on the sidelines of genomic studies. By involving their communities in genomic research, “whatever is going to be developed will also benefit our community,” says Dr. Teferra. “We will not be left out.”

A version of this article first appeared on Medscape.com.

In combing the genome, scientists can use genetic clues to determine a person’s risk for psychiatric disease and even identify new drug targets. But the benefits of these discoveries will be limited to people of European descent.

Nearly 90% of participants in genome-wide association studies (GWASs), which search for gene variants linked to disease, are of European ancestry. This Eurocentric focus threatens to widen existing disparities in racial and ethnic mental health.

The significant downsides of genomics’ one-track mind

One obstacle hindering therapeutic advances in psychiatry is a shallow understanding of the mechanisms of disorders. “The biggest problem in terms of advancing research for mental health conditions is that we don’t understand the underlying biology,” says Laramie Duncan, PhD, assistant professor of psychiatry and behavioral sciences at Stanford (Calif.) University. “Genetics is one of the best ways to systematically look for new clues about the underlying biology.”

At the advent of genomic research, scientists thought it best to study DNA from people of a single ancestry from one continent. “Researchers for a long time held the idea that it was going to be too complicated to include multiple ancestries in the first rounds of genetic analyses,” says Dr. Duncan.

Studying DNA from someone with ancestors from multiple parts of the world wasn’t compatible with methods used in the early days of GWASs. “Individual parts of a person’s DNA can be linked back to one region of the world or another, and most of our methods essentially assume that all of a person’s DNA came from one region of the world,” says Dr. Duncan.

Because many genes are usually involved in psychiatric disorders, scientists need large numbers of participants to detect uncommon, influential variants. Early research was concentrated in North America and Europe so that scientists could readily collect samples from people of European ancestry.

“It then went out of hand because it became routine practice to use only this one group, essentially White, European ancestry people,” says Karoline Kuchenbaecker, PhD, associate professor of psychiatry at University College London.

Yet findings from one population won’t necessarily translate to others. “And that’s exactly what has been shown,” says Dr. Teferra. Polygenic risk scores developed for schizophrenia from European samples, for example, perform poorly among people of African ancestry, although among Europeans, they are strongly effective at differentiating European individuals with and those without schizophrenia. Moreover, drugs that target a gene identified from studies in European populations may be harmful to other groups.

Studies drawn from a diverse pool of participants would benefit a wider swath of humanity. They would also allow scientists to discover small areas of overlap in genomes of different populations, which would help them close in on the true biology of diseases and ensure that “we’re all benefiting from more diverse data in genetics and psychiatric genetics,” says Dr. Kuchenbaecker.
 

New efforts aim at filling the gaps

Genomic studies are featuring more people of non-European ancestry, but most of that improvement comes from populations of Asian ancestry, not African, Latin American, or Indigenous ancestry.

Efforts to increase representation of persons of African ancestry have largely focused on African Americans; fewer efforts have extended to the African continent, home to the most genetically diverse populations. Even fewer have focused on mental health. “The little that was being done was on a very small scale,” says Karestan Koenen, PhD, a professor at Harvard School of Public Health, Boston.

With this in mind, researchers from institutions in Kenya, Uganda, South Africa, and Ethiopia partnered with researchers at the Broad Institute of the Massachusetts Institute of Technology and Harvard to conduct the largest GWAS of psychiatric disorders in Africa. Dr. Koenen leads the project, Neuropsychiatric Genetics of African Populations–Psychosis (NeuroGAP-Psychosis), which will analyze DNA from over 35,000 people of African ancestry in each of these four countries. Investigators will compare the half of participants who have no history of psychosis with the half with schizophrenia or bipolar disorder in the hopes of identifying the genetic determinants of psychosis.

“Then any potential intervention or therapeutics that will be developed will also be useful for Africans,” says Dr. Teferra, a NeuroGAP principal investigator. Because of the tremendous degree of genetic diversity among people on the continent, however, findings still might not translate to all African populations.

But correcting equity problems in genomics isn’t as simple as recruiting people with non-European backgrounds, especially if those people are unfamiliar with research or have been subject to scientific exploitation. “Special care needs to be taken to, first of all, provide information that’s appropriate [to participants], but also motivate people to take part and then find ways to keep these communities involved and understand what they’re interested in,” says Dr. Kuchenbaecker, who is not involved with NeuroGAP.

For NeuroGAP, the team needed to work with ethical committees at all of the institutions involved, ensure research materials were appropriate for each community’s cultural context, and gain the trust of local communities.

“One of the biggest criticisms within the scientific world is that people from more endowed countries just fly in, bully everyone, collect the data, and leave, with no credit to the local scientists or communities,” says NeuroGAP principal investigator Lukoye Atwoli, MMed, PhD, professor of psychiatry and dean of the Medical College, East Africa, at the Aga Khan University, Nairobi, Kenya. “That is one of the biggest pitfalls we had to grapple with.”

To address that concern, NeuroGAP is training local researchers and is providing them with requested resources so they can carry out similar studies in the future. “We will be looking to address a real need in the academic community and in clinical service delivery,” says Dr. Atwoli.

Dr. Kuchenbaecker says that NeuroGAP demonstrates features necessary for projects seeking to improve equity in psychiatric genomics. “What they’re doing right is recruiting really large numbers, recruiting from different African countries, and involving African investigators,” she says.

In the Americas, Janitza Montalvo-Ortiz, PhD, assistant professor in the Division of Genetics, department of psychiatry, Yale University, New Haven, Conn., and her colleagues are expanding psychiatric genomics projects in Latin America. She co-founded the Latin American Genomics Consortium in 2019, a network of scientists supporting psychiatric genomic research in the region. The consortium also involves the Neuropsychiatric Genetics in Mexican Populations project, which is similar to NeuroGAP and is also led by Dr. Koenan.

The study of Latin American populations is complicated, because genes in these populations reflect Indigenous American, European, and African ancestries. Even when investigators sampled DNA from Latin American individuals, that data often went unused. “Now with new methods emerging to allow us to properly analyze admixed populations in GWAS studies, we’re making efforts to compile different datasets scattered across different large-scale cohorts,” says Dr. Montalvo-Ortiz. “Our ultimate goal is to conduct the first large-scale LatinX GWAS of psychiatry,” she says.

With these projects, researchers hope that new psychiatric research will produce clinical advances for people historically left on the sidelines of genomic studies. By involving their communities in genomic research, “whatever is going to be developed will also benefit our community,” says Dr. Teferra. “We will not be left out.”

A version of this article first appeared on Medscape.com.

In combing the genome, scientists can use genetic clues to determine a person’s risk for psychiatric disease and even identify new drug targets. But the benefits of these discoveries will be limited to people of European descent.

Nearly 90% of participants in genome-wide association studies (GWASs), which search for gene variants linked to disease, are of European ancestry. This Eurocentric focus threatens to widen existing disparities in racial and ethnic mental health.

The significant downsides of genomics’ one-track mind

One obstacle hindering therapeutic advances in psychiatry is a shallow understanding of the mechanisms of disorders. “The biggest problem in terms of advancing research for mental health conditions is that we don’t understand the underlying biology,” says Laramie Duncan, PhD, assistant professor of psychiatry and behavioral sciences at Stanford (Calif.) University. “Genetics is one of the best ways to systematically look for new clues about the underlying biology.”

At the advent of genomic research, scientists thought it best to study DNA from people of a single ancestry from one continent. “Researchers for a long time held the idea that it was going to be too complicated to include multiple ancestries in the first rounds of genetic analyses,” says Dr. Duncan.

Studying DNA from someone with ancestors from multiple parts of the world wasn’t compatible with methods used in the early days of GWASs. “Individual parts of a person’s DNA can be linked back to one region of the world or another, and most of our methods essentially assume that all of a person’s DNA came from one region of the world,” says Dr. Duncan.

Because many genes are usually involved in psychiatric disorders, scientists need large numbers of participants to detect uncommon, influential variants. Early research was concentrated in North America and Europe so that scientists could readily collect samples from people of European ancestry.

“It then went out of hand because it became routine practice to use only this one group, essentially White, European ancestry people,” says Karoline Kuchenbaecker, PhD, associate professor of psychiatry at University College London.

Yet findings from one population won’t necessarily translate to others. “And that’s exactly what has been shown,” says Dr. Teferra. Polygenic risk scores developed for schizophrenia from European samples, for example, perform poorly among people of African ancestry, although among Europeans, they are strongly effective at differentiating European individuals with and those without schizophrenia. Moreover, drugs that target a gene identified from studies in European populations may be harmful to other groups.

Studies drawn from a diverse pool of participants would benefit a wider swath of humanity. They would also allow scientists to discover small areas of overlap in genomes of different populations, which would help them close in on the true biology of diseases and ensure that “we’re all benefiting from more diverse data in genetics and psychiatric genetics,” says Dr. Kuchenbaecker.
 

New efforts aim at filling the gaps

Genomic studies are featuring more people of non-European ancestry, but most of that improvement comes from populations of Asian ancestry, not African, Latin American, or Indigenous ancestry.

Efforts to increase representation of persons of African ancestry have largely focused on African Americans; fewer efforts have extended to the African continent, home to the most genetically diverse populations. Even fewer have focused on mental health. “The little that was being done was on a very small scale,” says Karestan Koenen, PhD, a professor at Harvard School of Public Health, Boston.

With this in mind, researchers from institutions in Kenya, Uganda, South Africa, and Ethiopia partnered with researchers at the Broad Institute of the Massachusetts Institute of Technology and Harvard to conduct the largest GWAS of psychiatric disorders in Africa. Dr. Koenen leads the project, Neuropsychiatric Genetics of African Populations–Psychosis (NeuroGAP-Psychosis), which will analyze DNA from over 35,000 people of African ancestry in each of these four countries. Investigators will compare the half of participants who have no history of psychosis with the half with schizophrenia or bipolar disorder in the hopes of identifying the genetic determinants of psychosis.

“Then any potential intervention or therapeutics that will be developed will also be useful for Africans,” says Dr. Teferra, a NeuroGAP principal investigator. Because of the tremendous degree of genetic diversity among people on the continent, however, findings still might not translate to all African populations.

But correcting equity problems in genomics isn’t as simple as recruiting people with non-European backgrounds, especially if those people are unfamiliar with research or have been subject to scientific exploitation. “Special care needs to be taken to, first of all, provide information that’s appropriate [to participants], but also motivate people to take part and then find ways to keep these communities involved and understand what they’re interested in,” says Dr. Kuchenbaecker, who is not involved with NeuroGAP.

For NeuroGAP, the team needed to work with ethical committees at all of the institutions involved, ensure research materials were appropriate for each community’s cultural context, and gain the trust of local communities.

“One of the biggest criticisms within the scientific world is that people from more endowed countries just fly in, bully everyone, collect the data, and leave, with no credit to the local scientists or communities,” says NeuroGAP principal investigator Lukoye Atwoli, MMed, PhD, professor of psychiatry and dean of the Medical College, East Africa, at the Aga Khan University, Nairobi, Kenya. “That is one of the biggest pitfalls we had to grapple with.”

To address that concern, NeuroGAP is training local researchers and is providing them with requested resources so they can carry out similar studies in the future. “We will be looking to address a real need in the academic community and in clinical service delivery,” says Dr. Atwoli.

Dr. Kuchenbaecker says that NeuroGAP demonstrates features necessary for projects seeking to improve equity in psychiatric genomics. “What they’re doing right is recruiting really large numbers, recruiting from different African countries, and involving African investigators,” she says.

In the Americas, Janitza Montalvo-Ortiz, PhD, assistant professor in the Division of Genetics, department of psychiatry, Yale University, New Haven, Conn., and her colleagues are expanding psychiatric genomics projects in Latin America. She co-founded the Latin American Genomics Consortium in 2019, a network of scientists supporting psychiatric genomic research in the region. The consortium also involves the Neuropsychiatric Genetics in Mexican Populations project, which is similar to NeuroGAP and is also led by Dr. Koenan.

The study of Latin American populations is complicated, because genes in these populations reflect Indigenous American, European, and African ancestries. Even when investigators sampled DNA from Latin American individuals, that data often went unused. “Now with new methods emerging to allow us to properly analyze admixed populations in GWAS studies, we’re making efforts to compile different datasets scattered across different large-scale cohorts,” says Dr. Montalvo-Ortiz. “Our ultimate goal is to conduct the first large-scale LatinX GWAS of psychiatry,” she says.

With these projects, researchers hope that new psychiatric research will produce clinical advances for people historically left on the sidelines of genomic studies. By involving their communities in genomic research, “whatever is going to be developed will also benefit our community,” says Dr. Teferra. “We will not be left out.”

A version of this article first appeared on Medscape.com.

Meditation, yoga, breathing exercises, and other mindfulness activities can help children with attention-deficit/hyperactivity disorder, but it’s not just the kids who benefit.

When families of children with ADHD complete a mindfulness program together, a new study suggests, children and parents can profit, with potential boosts to self-control, self-compassion, and psychological symptoms.

The findings do not suggest children should ditch medication in favor of focusing on the present moment. Instead, the study adds to growing evidence that mindfulness can be a helpful tool along with other strategies for children and adults with ADHD, said John Mitchell, PhD, a psychologist at Duke University, Durham, N.C., who was not involved with the new study. Mindfulness might help families ease stress and improve quality of life.

“We talk about ADHD because one person has that diagnosis, but we don’t live in bubbles,” he said. “We’re all interconnected and impact one another. And having treatments that acknowledge that and measuring that in the scientific literature is pretty important.”

Mindfulness training, which has its roots in Eastern traditions, generally aims to teach people how to be present in the moment and let go of judgment. Over the last couple of decades, researchers working on depression and other conditions have gathered evidence that practicing mindfulness can help in a variety of ways, including with the self-regulation of attention and emotions. It didn’t take long for those findings to draw interest from researchers who study ADHD, Dr. Mitchell said.

Research on mindfulness for ADHD started with adults, and results have been encouraging, Dr. Mitchell said. People who complete a mindfulness program tend to show some improvement in focus, impulsivity, and hyperactivity, studies show. In one small pilot study, Dr. Mitchell and colleagues reported improvements in symptoms and executive function in adults with ADHD.

Studies with children have lagged behind, but recent work has been promising. When looking at data from a number of studies, researchers have found small reductions in inattentiveness, hyperactivity, and impulsivity in young people with ADHD. Several randomized, controlled trials have also shown a reduction in symptoms as rated by parents and teachers.
 

Greater understanding, acceptance

In related research, there was a noticed reduction in stress among parents who get mindfulness training that teaches them to listen with their full attention, accept and develop compassion for themselves and their children, and regulate themselves within the relationship with their kids.

Still, first-line treatment for children with ADHD usually includes a combination of medication, cognitive behavioral therapy, and education, even though those strategies don’t always work well for everyone, says Corina Greven, PhD, a psychologist at Radboud (the Netherlands) University Medical Centre and Karakter Child and Adolescent Psychiatry.

Despite suggestive results, the data on mindfulness remains murky, in part because early studies that looked at mindfulness training for children with ADHD have been small. Few trials of mindfulness treatment for ADHD, Dr. Greven said, have included parents.

To fill in some of the gaps, Dr. Greven and colleagues conducted a trial with 103 families who had a child with ADHD between ages 8 and 16. Half of the families were randomly assigned simply to continue care as usual, which included medication for most.

The other half continued their usual care and also took part in a program called MYMind, which used mindfulness-based cognitive therapy for children and mindful parenting training for parents.

Families attended 90-minute group sessions once a week for 8 weeks, with an extra session 2 months later. The mindfulness group also completed homework every day that took about 30-45 minutes for parents and 15 minutes for children. Homework included workbooks and guided meditations.

In the short term, the team reported, children who received the mindfulness intervention showed small improvements in ADHD symptoms, anxiety, autistic symptoms, and problems falling asleep. One-third children who received mindfulness training improved on measures of self-control, Dr. Greven added, compared with just 1 in 10 who got only their usual care.

Benefits were larger and longer-lasting for parents. Compared with parents who didn’t get mindfulness training, those assigned to the mindfulness group improved in self-control, self-compassion, depression, anxiety, stress, well-being, and their own ADHD symptoms. Given a large genetic component to the disorder, it is common for parents of children with ADHD to have a diagnosis or ADHD symptoms as well. In addition, Dr. Greven said, families who completed the mindfulness-based intervention reported improvements in their relationships as well as acceptance of ADHD.
 

A new therapy?

The findings suggest new potential treatment options for children with ADHD, and for their parents, Dr. Greven said, as well as a need to study the condition more broadly. “Although parents of children with ADHD often have elevated parenting stress, anxiety, or their own ADHD symptoms, usual interventions for children with ADHD do not typically target parental mental health,” she said. “As researchers, we need to go broader than just looking at whether an intervention reduces symptoms and include additional outcomes that families find important.”

It will take more research to find out who is most likely to benefit from mindfulness training and how long those benefits last, but the new study is a useful starting point, experts say.

“Mindfulness training had potentially short-term and long-term beneficial effects to children with ADHD and their parents,” says Samuel Wong, MD, director of the JC School of Public Health and Primary Care at the Chinese University of Hong Kong. He says mindfulness is more likely to become an add-on than a replacement for other kinds of therapies.

“Clinicians may consider combining or adding family-based mindfulness training with current practice for children with ADHD who have residual symptoms with their current treatment,” he said.

Mindfulness training may help with issues beyond the classic symptoms that come with ADHD, Dr. Mitchell said, helping make family life better overall, even when some features of the disorder don’t budge much.

“With this study in particular, we see that we have some pretty promising effects that there may be something that will be beneficial above and beyond the core 18 DSM symptoms,” he said. “This is an important study, because it’s going to be a basis for the continuing evolution of the scientific research on this topic. It’s something to feel excited about.”

A version of this article first appeared on WebMD.com.

Meditation, yoga, breathing exercises, and other mindfulness activities can help children with attention-deficit/hyperactivity disorder, but it’s not just the kids who benefit.

When families of children with ADHD complete a mindfulness program together, a new study suggests, children and parents can profit, with potential boosts to self-control, self-compassion, and psychological symptoms.

The findings do not suggest children should ditch medication in favor of focusing on the present moment. Instead, the study adds to growing evidence that mindfulness can be a helpful tool along with other strategies for children and adults with ADHD, said John Mitchell, PhD, a psychologist at Duke University, Durham, N.C., who was not involved with the new study. Mindfulness might help families ease stress and improve quality of life.

“We talk about ADHD because one person has that diagnosis, but we don’t live in bubbles,” he said. “We’re all interconnected and impact one another. And having treatments that acknowledge that and measuring that in the scientific literature is pretty important.”

Mindfulness training, which has its roots in Eastern traditions, generally aims to teach people how to be present in the moment and let go of judgment. Over the last couple of decades, researchers working on depression and other conditions have gathered evidence that practicing mindfulness can help in a variety of ways, including with the self-regulation of attention and emotions. It didn’t take long for those findings to draw interest from researchers who study ADHD, Dr. Mitchell said.

Research on mindfulness for ADHD started with adults, and results have been encouraging, Dr. Mitchell said. People who complete a mindfulness program tend to show some improvement in focus, impulsivity, and hyperactivity, studies show. In one small pilot study, Dr. Mitchell and colleagues reported improvements in symptoms and executive function in adults with ADHD.

Studies with children have lagged behind, but recent work has been promising. When looking at data from a number of studies, researchers have found small reductions in inattentiveness, hyperactivity, and impulsivity in young people with ADHD. Several randomized, controlled trials have also shown a reduction in symptoms as rated by parents and teachers.
 

Greater understanding, acceptance

In related research, there was a noticed reduction in stress among parents who get mindfulness training that teaches them to listen with their full attention, accept and develop compassion for themselves and their children, and regulate themselves within the relationship with their kids.

Still, first-line treatment for children with ADHD usually includes a combination of medication, cognitive behavioral therapy, and education, even though those strategies don’t always work well for everyone, says Corina Greven, PhD, a psychologist at Radboud (the Netherlands) University Medical Centre and Karakter Child and Adolescent Psychiatry.

Despite suggestive results, the data on mindfulness remains murky, in part because early studies that looked at mindfulness training for children with ADHD have been small. Few trials of mindfulness treatment for ADHD, Dr. Greven said, have included parents.

To fill in some of the gaps, Dr. Greven and colleagues conducted a trial with 103 families who had a child with ADHD between ages 8 and 16. Half of the families were randomly assigned simply to continue care as usual, which included medication for most.

The other half continued their usual care and also took part in a program called MYMind, which used mindfulness-based cognitive therapy for children and mindful parenting training for parents.

Families attended 90-minute group sessions once a week for 8 weeks, with an extra session 2 months later. The mindfulness group also completed homework every day that took about 30-45 minutes for parents and 15 minutes for children. Homework included workbooks and guided meditations.

In the short term, the team reported, children who received the mindfulness intervention showed small improvements in ADHD symptoms, anxiety, autistic symptoms, and problems falling asleep. One-third children who received mindfulness training improved on measures of self-control, Dr. Greven added, compared with just 1 in 10 who got only their usual care.

Benefits were larger and longer-lasting for parents. Compared with parents who didn’t get mindfulness training, those assigned to the mindfulness group improved in self-control, self-compassion, depression, anxiety, stress, well-being, and their own ADHD symptoms. Given a large genetic component to the disorder, it is common for parents of children with ADHD to have a diagnosis or ADHD symptoms as well. In addition, Dr. Greven said, families who completed the mindfulness-based intervention reported improvements in their relationships as well as acceptance of ADHD.
 

A new therapy?

The findings suggest new potential treatment options for children with ADHD, and for their parents, Dr. Greven said, as well as a need to study the condition more broadly. “Although parents of children with ADHD often have elevated parenting stress, anxiety, or their own ADHD symptoms, usual interventions for children with ADHD do not typically target parental mental health,” she said. “As researchers, we need to go broader than just looking at whether an intervention reduces symptoms and include additional outcomes that families find important.”

It will take more research to find out who is most likely to benefit from mindfulness training and how long those benefits last, but the new study is a useful starting point, experts say.

“Mindfulness training had potentially short-term and long-term beneficial effects to children with ADHD and their parents,” says Samuel Wong, MD, director of the JC School of Public Health and Primary Care at the Chinese University of Hong Kong. He says mindfulness is more likely to become an add-on than a replacement for other kinds of therapies.

“Clinicians may consider combining or adding family-based mindfulness training with current practice for children with ADHD who have residual symptoms with their current treatment,” he said.

Mindfulness training may help with issues beyond the classic symptoms that come with ADHD, Dr. Mitchell said, helping make family life better overall, even when some features of the disorder don’t budge much.

“With this study in particular, we see that we have some pretty promising effects that there may be something that will be beneficial above and beyond the core 18 DSM symptoms,” he said. “This is an important study, because it’s going to be a basis for the continuing evolution of the scientific research on this topic. It’s something to feel excited about.”

A version of this article first appeared on WebMD.com.

Meditation, yoga, breathing exercises, and other mindfulness activities can help children with attention-deficit/hyperactivity disorder, but it’s not just the kids who benefit.

When families of children with ADHD complete a mindfulness program together, a new study suggests, children and parents can profit, with potential boosts to self-control, self-compassion, and psychological symptoms.

The findings do not suggest children should ditch medication in favor of focusing on the present moment. Instead, the study adds to growing evidence that mindfulness can be a helpful tool along with other strategies for children and adults with ADHD, said John Mitchell, PhD, a psychologist at Duke University, Durham, N.C., who was not involved with the new study. Mindfulness might help families ease stress and improve quality of life.

“We talk about ADHD because one person has that diagnosis, but we don’t live in bubbles,” he said. “We’re all interconnected and impact one another. And having treatments that acknowledge that and measuring that in the scientific literature is pretty important.”

Mindfulness training, which has its roots in Eastern traditions, generally aims to teach people how to be present in the moment and let go of judgment. Over the last couple of decades, researchers working on depression and other conditions have gathered evidence that practicing mindfulness can help in a variety of ways, including with the self-regulation of attention and emotions. It didn’t take long for those findings to draw interest from researchers who study ADHD, Dr. Mitchell said.

Research on mindfulness for ADHD started with adults, and results have been encouraging, Dr. Mitchell said. People who complete a mindfulness program tend to show some improvement in focus, impulsivity, and hyperactivity, studies show. In one small pilot study, Dr. Mitchell and colleagues reported improvements in symptoms and executive function in adults with ADHD.

Studies with children have lagged behind, but recent work has been promising. When looking at data from a number of studies, researchers have found small reductions in inattentiveness, hyperactivity, and impulsivity in young people with ADHD. Several randomized, controlled trials have also shown a reduction in symptoms as rated by parents and teachers.
 

Greater understanding, acceptance

In related research, there was a noticed reduction in stress among parents who get mindfulness training that teaches them to listen with their full attention, accept and develop compassion for themselves and their children, and regulate themselves within the relationship with their kids.

Still, first-line treatment for children with ADHD usually includes a combination of medication, cognitive behavioral therapy, and education, even though those strategies don’t always work well for everyone, says Corina Greven, PhD, a psychologist at Radboud (the Netherlands) University Medical Centre and Karakter Child and Adolescent Psychiatry.

Despite suggestive results, the data on mindfulness remains murky, in part because early studies that looked at mindfulness training for children with ADHD have been small. Few trials of mindfulness treatment for ADHD, Dr. Greven said, have included parents.

To fill in some of the gaps, Dr. Greven and colleagues conducted a trial with 103 families who had a child with ADHD between ages 8 and 16. Half of the families were randomly assigned simply to continue care as usual, which included medication for most.

The other half continued their usual care and also took part in a program called MYMind, which used mindfulness-based cognitive therapy for children and mindful parenting training for parents.

Families attended 90-minute group sessions once a week for 8 weeks, with an extra session 2 months later. The mindfulness group also completed homework every day that took about 30-45 minutes for parents and 15 minutes for children. Homework included workbooks and guided meditations.

In the short term, the team reported, children who received the mindfulness intervention showed small improvements in ADHD symptoms, anxiety, autistic symptoms, and problems falling asleep. One-third children who received mindfulness training improved on measures of self-control, Dr. Greven added, compared with just 1 in 10 who got only their usual care.

Benefits were larger and longer-lasting for parents. Compared with parents who didn’t get mindfulness training, those assigned to the mindfulness group improved in self-control, self-compassion, depression, anxiety, stress, well-being, and their own ADHD symptoms. Given a large genetic component to the disorder, it is common for parents of children with ADHD to have a diagnosis or ADHD symptoms as well. In addition, Dr. Greven said, families who completed the mindfulness-based intervention reported improvements in their relationships as well as acceptance of ADHD.
 

A new therapy?

The findings suggest new potential treatment options for children with ADHD, and for their parents, Dr. Greven said, as well as a need to study the condition more broadly. “Although parents of children with ADHD often have elevated parenting stress, anxiety, or their own ADHD symptoms, usual interventions for children with ADHD do not typically target parental mental health,” she said. “As researchers, we need to go broader than just looking at whether an intervention reduces symptoms and include additional outcomes that families find important.”

It will take more research to find out who is most likely to benefit from mindfulness training and how long those benefits last, but the new study is a useful starting point, experts say.

“Mindfulness training had potentially short-term and long-term beneficial effects to children with ADHD and their parents,” says Samuel Wong, MD, director of the JC School of Public Health and Primary Care at the Chinese University of Hong Kong. He says mindfulness is more likely to become an add-on than a replacement for other kinds of therapies.

“Clinicians may consider combining or adding family-based mindfulness training with current practice for children with ADHD who have residual symptoms with their current treatment,” he said.

Mindfulness training may help with issues beyond the classic symptoms that come with ADHD, Dr. Mitchell said, helping make family life better overall, even when some features of the disorder don’t budge much.

“With this study in particular, we see that we have some pretty promising effects that there may be something that will be beneficial above and beyond the core 18 DSM symptoms,” he said. “This is an important study, because it’s going to be a basis for the continuing evolution of the scientific research on this topic. It’s something to feel excited about.”

A version of this article first appeared on WebMD.com.

Calming wall colors, nature-themed murals, and soft nighttime lighting are all part of a unique new state-of-the-art inpatient psychiatric unit that focuses especially on children and adolescents who have experienced significant trauma.

The 16-bed unit, which has been in the works for 3½ years and opened June 30 at the University of Maryland Medical Center (UMMC), in Baltimore, Maryland, treats youth aged 5 to 17 years. It has separate wings for younger children and for adolescents.

Safety first

Typical conditions treated at the new unit will include depression, anxiety, attention-deficit/hyperactivity disorder, psychotic spectrum, as well as trauma disorders.

Some of these young patients have been through the foster care system and show signs of trauma and poor attachment, Dr. Edwards noted. As a result, they may have difficulty regulating their thoughts and emotions and at times exhibit dangerous behavior.

The new unit is designed both architecturally and clinically to deliver “trauma-informed” care. This type of approach “recognizes the pervasive nature of trauma” and promotes settings that facilitate recovery, Dr. Edwards added.

The idea is to treat individuals “in a way that doesn’t re-traumatize them or make their condition worse,” she added.

Circadian-rhythm lighting

Other unique elements of the new unit include walls painted soothing shades and murals of natural scenery, created by a local artist.

These murals perfectly capture “the kind of overall spirit of what we were trying to induce,” said Dr. Edwards.

A part of the unit dubbed the “front porch” has a large mural depicting “a landscape of beautiful trees and water and animals,” she noted. Kids can gather here to relax or just hang out.

The lighting at the unit mirrors circadian rhythms. It’s brighter during the day to promote wakefulness and participation in activities and gradually dims toward the evening hours to help induce restful nighttime sleep.

Safe and empowering environments such as those created by the unit help young patients learn to manage their intense emotions and adopt productive behaviors and coping skills, Dr. Edwards noted.

The staff for the interprofessional unit includes psychiatrists, psychologists, psychiatric nurses, occupational therapists, and others trained in pediatric care.
 

Advice for other centers

“Our new unit is designed to provide the highest standard in mental health care and incorporates a high-tech approach to create a calming, soothing, and engaging setting,” said Dr. RachBeisel.

School-transition specialists help connect discharged patients and their families to vital services and peer support. These services represent “an essential component of the continuum of care” for youth experiencing mental distress, she added.

Other organizations considering establishing a similar type of psychiatric unit should consult all stakeholders.

“We had staff, no matter what their role, be part of every step of this process, including helping with the design, picking out furniture they thought would make the most sense, and helping choose the artwork,” she said.

It is also important to incorporate feedback from youth themselves, Dr. Edwards added.

A version of this article first appeared on Medscape.com.

Calming wall colors, nature-themed murals, and soft nighttime lighting are all part of a unique new state-of-the-art inpatient psychiatric unit that focuses especially on children and adolescents who have experienced significant trauma.

The 16-bed unit, which has been in the works for 3½ years and opened June 30 at the University of Maryland Medical Center (UMMC), in Baltimore, Maryland, treats youth aged 5 to 17 years. It has separate wings for younger children and for adolescents.

Safety first

Typical conditions treated at the new unit will include depression, anxiety, attention-deficit/hyperactivity disorder, psychotic spectrum, as well as trauma disorders.

Some of these young patients have been through the foster care system and show signs of trauma and poor attachment, Dr. Edwards noted. As a result, they may have difficulty regulating their thoughts and emotions and at times exhibit dangerous behavior.

The new unit is designed both architecturally and clinically to deliver “trauma-informed” care. This type of approach “recognizes the pervasive nature of trauma” and promotes settings that facilitate recovery, Dr. Edwards added.

The idea is to treat individuals “in a way that doesn’t re-traumatize them or make their condition worse,” she added.

Circadian-rhythm lighting

Other unique elements of the new unit include walls painted soothing shades and murals of natural scenery, created by a local artist.

These murals perfectly capture “the kind of overall spirit of what we were trying to induce,” said Dr. Edwards.

A part of the unit dubbed the “front porch” has a large mural depicting “a landscape of beautiful trees and water and animals,” she noted. Kids can gather here to relax or just hang out.

The lighting at the unit mirrors circadian rhythms. It’s brighter during the day to promote wakefulness and participation in activities and gradually dims toward the evening hours to help induce restful nighttime sleep.

Safe and empowering environments such as those created by the unit help young patients learn to manage their intense emotions and adopt productive behaviors and coping skills, Dr. Edwards noted.

The staff for the interprofessional unit includes psychiatrists, psychologists, psychiatric nurses, occupational therapists, and others trained in pediatric care.
 

Advice for other centers

“Our new unit is designed to provide the highest standard in mental health care and incorporates a high-tech approach to create a calming, soothing, and engaging setting,” said Dr. RachBeisel.

School-transition specialists help connect discharged patients and their families to vital services and peer support. These services represent “an essential component of the continuum of care” for youth experiencing mental distress, she added.

Other organizations considering establishing a similar type of psychiatric unit should consult all stakeholders.

“We had staff, no matter what their role, be part of every step of this process, including helping with the design, picking out furniture they thought would make the most sense, and helping choose the artwork,” she said.

It is also important to incorporate feedback from youth themselves, Dr. Edwards added.

A version of this article first appeared on Medscape.com.

Calming wall colors, nature-themed murals, and soft nighttime lighting are all part of a unique new state-of-the-art inpatient psychiatric unit that focuses especially on children and adolescents who have experienced significant trauma.

The 16-bed unit, which has been in the works for 3½ years and opened June 30 at the University of Maryland Medical Center (UMMC), in Baltimore, Maryland, treats youth aged 5 to 17 years. It has separate wings for younger children and for adolescents.

Safety first

Typical conditions treated at the new unit will include depression, anxiety, attention-deficit/hyperactivity disorder, psychotic spectrum, as well as trauma disorders.

Some of these young patients have been through the foster care system and show signs of trauma and poor attachment, Dr. Edwards noted. As a result, they may have difficulty regulating their thoughts and emotions and at times exhibit dangerous behavior.

The new unit is designed both architecturally and clinically to deliver “trauma-informed” care. This type of approach “recognizes the pervasive nature of trauma” and promotes settings that facilitate recovery, Dr. Edwards added.

The idea is to treat individuals “in a way that doesn’t re-traumatize them or make their condition worse,” she added.

Circadian-rhythm lighting

Other unique elements of the new unit include walls painted soothing shades and murals of natural scenery, created by a local artist.

These murals perfectly capture “the kind of overall spirit of what we were trying to induce,” said Dr. Edwards.

A part of the unit dubbed the “front porch” has a large mural depicting “a landscape of beautiful trees and water and animals,” she noted. Kids can gather here to relax or just hang out.

The lighting at the unit mirrors circadian rhythms. It’s brighter during the day to promote wakefulness and participation in activities and gradually dims toward the evening hours to help induce restful nighttime sleep.

Safe and empowering environments such as those created by the unit help young patients learn to manage their intense emotions and adopt productive behaviors and coping skills, Dr. Edwards noted.

The staff for the interprofessional unit includes psychiatrists, psychologists, psychiatric nurses, occupational therapists, and others trained in pediatric care.
 

Advice for other centers

“Our new unit is designed to provide the highest standard in mental health care and incorporates a high-tech approach to create a calming, soothing, and engaging setting,” said Dr. RachBeisel.

School-transition specialists help connect discharged patients and their families to vital services and peer support. These services represent “an essential component of the continuum of care” for youth experiencing mental distress, she added.

Other organizations considering establishing a similar type of psychiatric unit should consult all stakeholders.

“We had staff, no matter what their role, be part of every step of this process, including helping with the design, picking out furniture they thought would make the most sense, and helping choose the artwork,” she said.

It is also important to incorporate feedback from youth themselves, Dr. Edwards added.

A version of this article first appeared on Medscape.com.

A stimulant used in patients with attention-deficit/hyperactivity disorder might prove useful for other comorbid symptoms, results of a randomized, crossover trial suggest.

In the trial, the investigators reported that lisdexamfetamine (Vyvanse) reduced self-reported symptoms of sluggish cognitive tempo (SCT) by 30%, in addition to lowering ADHD symptoms by more than 40%.

The drug also corrected deficits in executive brain function. Patients had fewer episodes of procrastination, were better able to prioritize, and showed improvements in keeping things in mind.

“These findings highlight the importance of assessing symptoms of sluggish cognitive tempo and executive brain function in patients when they are initially diagnosed with ADHD,” Lenard A. Adler, MD, the lead author, said in a press release. The results were published June 29, 2021, in the Journal of Clinical Psychiatry.

The trial is groundbreaking because it is the first treatment study for ADHD with SCT in adults, Dr. Adler, director of the adult ADHD program at New York University Langone Health, said in an interview. He said that Russell A. Barkley, PhD, a clinical professor of psychiatry at Virginia Commonwealth University, Richmond, defines SCT as having nine cardinal symptoms: prone to daydreaming, easy boredom, trouble staying awake, feeling foggy, spaciness, lethargy, underachieving, less energy, and not processing information quickly or accurately.

Dr. Barkley, who studied more than 1,200 individuals with SCT, discovered that nearly half also had ADHD, Dr. Adler said. Those with the comorbid symptoms also had more impairment.

Whether or not the symptom set of SCT is a distinct disorder or a cotraveling symptom set that goes along with ADHD has been an area of investigation, said Dr. Adler, also a professor in the departments of psychiatry and child and adolescent psychiatry at New York University. Other known comorbid symptoms include executive function deficits and trouble with emotional control.

Stimulants to date have only shown success in children, as far as improving SCT. The goal of this study was to determine the efficacy of lisdexamfetamine on the nature and severity of ADHD symptoms and SCT behavioral indicators in adults with ADHD and SCT.
 

Two cohorts, alternating regimens

The investigators enrolled 38 adults with DSM-5 ADHD and SCT. Patients were recruited from two academic centers, New York University and the Icahn School of Medicine at Mount Sinai. The randomized 10-week crossover trial included two double-blind treatment periods, each 4 weeks long, with an intervening 2-week, single-blind placebo washout period.

“In crossover design, patients act as their own control, because they receive both treatments,” Dr. Adler said. Recruiting a smaller number of subjects helps to achieve significance in results.

For the first 4 weeks, participants received daily doses of either lisdexamfetamine (30-70 mg/day; mean, 59.1 mg/day) or a placebo sugar pill (mean, 66.6 mg/day). Researchers used standardized tests for SCT signs and symptoms, ADHD, and other measures of brain function to track psychiatric health on a weekly basis. After a month, the two cohorts switched regimens – those taking the placebo started the daily doses of lisdexamfetamine, and the other half stopped the drug and started taking the placebo.

Primary outcomes included the ADHD Rating Scale and Barkley Adult ADHD Rating Scale-IV SCT subscale.

Compared with placebo, adults with ADHD and comorbid SCT showed significant improvement after taking lisdexamfetamine in ratings of SCT and total ADHD symptoms. This was also true of other comorbid symptoms, such as executive function deficits.

In the crossover design, patients who received the drug first hadn’t gone fully back to baseline by the time the investigators crossed them over into the placebo group. “So, we couldn’t combine the two treatment epochs,” Dr. Adler said. However, the effect of the drug versus placebo was comparable in both study arms.
 

SCT alone was not studied

The trial had some limitations, mainly that it was an initial study with a modest sample size, Dr. Adler said. It also did not examine SCT alone, “so we can’t really say whether the stimulant medicine would improve SCT in patients who don’t have ADHD. What’s notable is when you look at how much of the improvement in SCT was due to improvement in ADHD, it was just 25%.” This means the effects occurring on SCT symptoms were not solely caused by effects on ADHD.

“We can’t say definitively that patients without SCT would respond to a stimulant. That’s a subject for future study,” he said.

Dr. Adler would like to see treatment studies of adults with ADHD and SCT in a larger sample, potentially with other stimulants. In addition, future trials could examine the effects of stimulants on adults with SCT that do not have ADHD.

The results of this trial underscore the importance of evaluating adults with ADHD for comorbid symptoms, such as executive function and emotional control, he continued. “Impairing SCT symptoms may very well fall under that umbrella,” Dr. Adler said. “If you don’t identify them, you can’t track them in terms of treatment.”
 

SCT as a ‘flavor’ of ADHD

The outcome of this study demonstrates that lisdexamfetamine significantly improves both ADHD symptoms and SCT symptoms, said David W. Goodman MD, LFAPA, an assistant professor in the department of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore.

Dr. Goodman, who was not involved in the study, agreed that clinicians should be aware of SCT when assessing adults with ADHD and conceptualize SCT as a “flavor” of ADHD. “SCT is not widely recognized by clinicians outside of the research arena but will likely become an important characteristic of ADHD presentation,” he said in an interview.

“Future studies in adult ADHD should further clarify the prevalence of SCT in the ADHD population and address more specific effective treatment options,” he said.

James M. Swanson, PhD, who also was not involved with the study, agreed in an interview that it documents the clear short-term benefit of stimulants on symptoms of SCT. The study “may be very timely, since adults who were affected by COVID-19 often have residual sequelae manifested as ‘brain fog,’ which resemble SCT,” said Dr. Swanson, professor of pediatrics at the University of California, Irvine.

The study was funded by Takeda Pharmaceutical, manufacturer of lisdexamfetamine. Dr. Adler has received grant/research support and has served as a consultant from Shire/Takeda and other companies. Dr. Goodman is a scientific consultant to Takeda and other pharmaceutical companies in the ADHD arena. Dr. Swanson had no disclosures.

A stimulant used in patients with attention-deficit/hyperactivity disorder might prove useful for other comorbid symptoms, results of a randomized, crossover trial suggest.

In the trial, the investigators reported that lisdexamfetamine (Vyvanse) reduced self-reported symptoms of sluggish cognitive tempo (SCT) by 30%, in addition to lowering ADHD symptoms by more than 40%.

The drug also corrected deficits in executive brain function. Patients had fewer episodes of procrastination, were better able to prioritize, and showed improvements in keeping things in mind.

“These findings highlight the importance of assessing symptoms of sluggish cognitive tempo and executive brain function in patients when they are initially diagnosed with ADHD,” Lenard A. Adler, MD, the lead author, said in a press release. The results were published June 29, 2021, in the Journal of Clinical Psychiatry.

The trial is groundbreaking because it is the first treatment study for ADHD with SCT in adults, Dr. Adler, director of the adult ADHD program at New York University Langone Health, said in an interview. He said that Russell A. Barkley, PhD, a clinical professor of psychiatry at Virginia Commonwealth University, Richmond, defines SCT as having nine cardinal symptoms: prone to daydreaming, easy boredom, trouble staying awake, feeling foggy, spaciness, lethargy, underachieving, less energy, and not processing information quickly or accurately.

Dr. Barkley, who studied more than 1,200 individuals with SCT, discovered that nearly half also had ADHD, Dr. Adler said. Those with the comorbid symptoms also had more impairment.

Whether or not the symptom set of SCT is a distinct disorder or a cotraveling symptom set that goes along with ADHD has been an area of investigation, said Dr. Adler, also a professor in the departments of psychiatry and child and adolescent psychiatry at New York University. Other known comorbid symptoms include executive function deficits and trouble with emotional control.

Stimulants to date have only shown success in children, as far as improving SCT. The goal of this study was to determine the efficacy of lisdexamfetamine on the nature and severity of ADHD symptoms and SCT behavioral indicators in adults with ADHD and SCT.
 

Two cohorts, alternating regimens

The investigators enrolled 38 adults with DSM-5 ADHD and SCT. Patients were recruited from two academic centers, New York University and the Icahn School of Medicine at Mount Sinai. The randomized 10-week crossover trial included two double-blind treatment periods, each 4 weeks long, with an intervening 2-week, single-blind placebo washout period.

“In crossover design, patients act as their own control, because they receive both treatments,” Dr. Adler said. Recruiting a smaller number of subjects helps to achieve significance in results.

For the first 4 weeks, participants received daily doses of either lisdexamfetamine (30-70 mg/day; mean, 59.1 mg/day) or a placebo sugar pill (mean, 66.6 mg/day). Researchers used standardized tests for SCT signs and symptoms, ADHD, and other measures of brain function to track psychiatric health on a weekly basis. After a month, the two cohorts switched regimens – those taking the placebo started the daily doses of lisdexamfetamine, and the other half stopped the drug and started taking the placebo.

Primary outcomes included the ADHD Rating Scale and Barkley Adult ADHD Rating Scale-IV SCT subscale.

Compared with placebo, adults with ADHD and comorbid SCT showed significant improvement after taking lisdexamfetamine in ratings of SCT and total ADHD symptoms. This was also true of other comorbid symptoms, such as executive function deficits.

In the crossover design, patients who received the drug first hadn’t gone fully back to baseline by the time the investigators crossed them over into the placebo group. “So, we couldn’t combine the two treatment epochs,” Dr. Adler said. However, the effect of the drug versus placebo was comparable in both study arms.
 

SCT alone was not studied

The trial had some limitations, mainly that it was an initial study with a modest sample size, Dr. Adler said. It also did not examine SCT alone, “so we can’t really say whether the stimulant medicine would improve SCT in patients who don’t have ADHD. What’s notable is when you look at how much of the improvement in SCT was due to improvement in ADHD, it was just 25%.” This means the effects occurring on SCT symptoms were not solely caused by effects on ADHD.

“We can’t say definitively that patients without SCT would respond to a stimulant. That’s a subject for future study,” he said.

Dr. Adler would like to see treatment studies of adults with ADHD and SCT in a larger sample, potentially with other stimulants. In addition, future trials could examine the effects of stimulants on adults with SCT that do not have ADHD.

The results of this trial underscore the importance of evaluating adults with ADHD for comorbid symptoms, such as executive function and emotional control, he continued. “Impairing SCT symptoms may very well fall under that umbrella,” Dr. Adler said. “If you don’t identify them, you can’t track them in terms of treatment.”
 

SCT as a ‘flavor’ of ADHD

The outcome of this study demonstrates that lisdexamfetamine significantly improves both ADHD symptoms and SCT symptoms, said David W. Goodman MD, LFAPA, an assistant professor in the department of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore.

Dr. Goodman, who was not involved in the study, agreed that clinicians should be aware of SCT when assessing adults with ADHD and conceptualize SCT as a “flavor” of ADHD. “SCT is not widely recognized by clinicians outside of the research arena but will likely become an important characteristic of ADHD presentation,” he said in an interview.

“Future studies in adult ADHD should further clarify the prevalence of SCT in the ADHD population and address more specific effective treatment options,” he said.

James M. Swanson, PhD, who also was not involved with the study, agreed in an interview that it documents the clear short-term benefit of stimulants on symptoms of SCT. The study “may be very timely, since adults who were affected by COVID-19 often have residual sequelae manifested as ‘brain fog,’ which resemble SCT,” said Dr. Swanson, professor of pediatrics at the University of California, Irvine.

The study was funded by Takeda Pharmaceutical, manufacturer of lisdexamfetamine. Dr. Adler has received grant/research support and has served as a consultant from Shire/Takeda and other companies. Dr. Goodman is a scientific consultant to Takeda and other pharmaceutical companies in the ADHD arena. Dr. Swanson had no disclosures.

A stimulant used in patients with attention-deficit/hyperactivity disorder might prove useful for other comorbid symptoms, results of a randomized, crossover trial suggest.

In the trial, the investigators reported that lisdexamfetamine (Vyvanse) reduced self-reported symptoms of sluggish cognitive tempo (SCT) by 30%, in addition to lowering ADHD symptoms by more than 40%.

The drug also corrected deficits in executive brain function. Patients had fewer episodes of procrastination, were better able to prioritize, and showed improvements in keeping things in mind.

“These findings highlight the importance of assessing symptoms of sluggish cognitive tempo and executive brain function in patients when they are initially diagnosed with ADHD,” Lenard A. Adler, MD, the lead author, said in a press release. The results were published June 29, 2021, in the Journal of Clinical Psychiatry.

The trial is groundbreaking because it is the first treatment study for ADHD with SCT in adults, Dr. Adler, director of the adult ADHD program at New York University Langone Health, said in an interview. He said that Russell A. Barkley, PhD, a clinical professor of psychiatry at Virginia Commonwealth University, Richmond, defines SCT as having nine cardinal symptoms: prone to daydreaming, easy boredom, trouble staying awake, feeling foggy, spaciness, lethargy, underachieving, less energy, and not processing information quickly or accurately.

Dr. Barkley, who studied more than 1,200 individuals with SCT, discovered that nearly half also had ADHD, Dr. Adler said. Those with the comorbid symptoms also had more impairment.

Whether or not the symptom set of SCT is a distinct disorder or a cotraveling symptom set that goes along with ADHD has been an area of investigation, said Dr. Adler, also a professor in the departments of psychiatry and child and adolescent psychiatry at New York University. Other known comorbid symptoms include executive function deficits and trouble with emotional control.

Stimulants to date have only shown success in children, as far as improving SCT. The goal of this study was to determine the efficacy of lisdexamfetamine on the nature and severity of ADHD symptoms and SCT behavioral indicators in adults with ADHD and SCT.
 

Two cohorts, alternating regimens

The investigators enrolled 38 adults with DSM-5 ADHD and SCT. Patients were recruited from two academic centers, New York University and the Icahn School of Medicine at Mount Sinai. The randomized 10-week crossover trial included two double-blind treatment periods, each 4 weeks long, with an intervening 2-week, single-blind placebo washout period.

“In crossover design, patients act as their own control, because they receive both treatments,” Dr. Adler said. Recruiting a smaller number of subjects helps to achieve significance in results.

For the first 4 weeks, participants received daily doses of either lisdexamfetamine (30-70 mg/day; mean, 59.1 mg/day) or a placebo sugar pill (mean, 66.6 mg/day). Researchers used standardized tests for SCT signs and symptoms, ADHD, and other measures of brain function to track psychiatric health on a weekly basis. After a month, the two cohorts switched regimens – those taking the placebo started the daily doses of lisdexamfetamine, and the other half stopped the drug and started taking the placebo.

Primary outcomes included the ADHD Rating Scale and Barkley Adult ADHD Rating Scale-IV SCT subscale.

Compared with placebo, adults with ADHD and comorbid SCT showed significant improvement after taking lisdexamfetamine in ratings of SCT and total ADHD symptoms. This was also true of other comorbid symptoms, such as executive function deficits.

In the crossover design, patients who received the drug first hadn’t gone fully back to baseline by the time the investigators crossed them over into the placebo group. “So, we couldn’t combine the two treatment epochs,” Dr. Adler said. However, the effect of the drug versus placebo was comparable in both study arms.
 

SCT alone was not studied

The trial had some limitations, mainly that it was an initial study with a modest sample size, Dr. Adler said. It also did not examine SCT alone, “so we can’t really say whether the stimulant medicine would improve SCT in patients who don’t have ADHD. What’s notable is when you look at how much of the improvement in SCT was due to improvement in ADHD, it was just 25%.” This means the effects occurring on SCT symptoms were not solely caused by effects on ADHD.

“We can’t say definitively that patients without SCT would respond to a stimulant. That’s a subject for future study,” he said.

Dr. Adler would like to see treatment studies of adults with ADHD and SCT in a larger sample, potentially with other stimulants. In addition, future trials could examine the effects of stimulants on adults with SCT that do not have ADHD.

The results of this trial underscore the importance of evaluating adults with ADHD for comorbid symptoms, such as executive function and emotional control, he continued. “Impairing SCT symptoms may very well fall under that umbrella,” Dr. Adler said. “If you don’t identify them, you can’t track them in terms of treatment.”
 

SCT as a ‘flavor’ of ADHD

The outcome of this study demonstrates that lisdexamfetamine significantly improves both ADHD symptoms and SCT symptoms, said David W. Goodman MD, LFAPA, an assistant professor in the department of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore.

Dr. Goodman, who was not involved in the study, agreed that clinicians should be aware of SCT when assessing adults with ADHD and conceptualize SCT as a “flavor” of ADHD. “SCT is not widely recognized by clinicians outside of the research arena but will likely become an important characteristic of ADHD presentation,” he said in an interview.

“Future studies in adult ADHD should further clarify the prevalence of SCT in the ADHD population and address more specific effective treatment options,” he said.

James M. Swanson, PhD, who also was not involved with the study, agreed in an interview that it documents the clear short-term benefit of stimulants on symptoms of SCT. The study “may be very timely, since adults who were affected by COVID-19 often have residual sequelae manifested as ‘brain fog,’ which resemble SCT,” said Dr. Swanson, professor of pediatrics at the University of California, Irvine.

The study was funded by Takeda Pharmaceutical, manufacturer of lisdexamfetamine. Dr. Adler has received grant/research support and has served as a consultant from Shire/Takeda and other companies. Dr. Goodman is a scientific consultant to Takeda and other pharmaceutical companies in the ADHD arena. Dr. Swanson had no disclosures.

Young people with gender dysphoria should be considered as individuals rather than fall into an age-defined bracket when assessing their understanding to consent to hormone treatment, according to the Tavistock and Portman NHS Foundation Trust, as it awaits the verdict of its recent appeal in London against a High Court ruling. 

The High Court ruling, made in December 2020 as reported by this news organization, stated that adolescents with gender dysphoria were unlikely to fully understand the consequences of hormone treatment for gender reassignment and was the result of a case brought by 24-year-old Keira Bell, who transitioned from female to male at the Gender Identity Development Service (GIDS), starting at the age of 16, but later “detransitioned.”

Along with changes made to rules around prescribing puberty blockers and cross-sex hormones to minors with gender dysphoria in countries such as Finland and Sweden, the English ruling signals a more cautious approach to any medical treatment for such children, as detailed in a feature published in April.

However, during the appeal, The Trust argued once more that puberty blockers give children time to “consider options” about their bodies and that the decision (the December ruling) was inconsistent with the law that “entitles children under the age of 16 to make decisions for themselves after being assessed as competent to do so by their doctor.”

Alongside other organizations, the United States–based Endocrine Society submitted written evidence in support of the Tavistock. “The High Court’s decision, if it is allowed to stand, would set a harmful precedent preventing physicians from providing transgender and gender diverse youth with high-quality medical care,” it noted in a statement.

Defending the High Court’s ruling, the lawyer for Ms. Bell said its conclusion was that puberty blockers for gender dysphoria are an “experimental” treatment with a very limited evidence base.

“The judgment of the [High Court] is entirely correct, and there is no proper basis for overturning it,” he asserted.

The 2-day appeal hearing ended on June 24, and a ruling will be made at a later date.
 

Do children understand the consequences of hormone treatment?

One central aspect of the overall case is the fact that Ms. Bell regrets her decision to transition at age 16, saying she only received three counseling sessions prior to endocrinology referral. And she consequently had a mastectomy at age 20, which she also bitterly regrets.

So a key concern is whether young people fully understand the consequences of taking puberty blockers and therapies that may follow, including cross-sex hormones.

Witness for the appeal Gary Butler, MD, consultant in pediatric and adolescent endocrinology at University College Hospital, London, where children are referred to from GIDS for hormone treatment, said the number of children who go on to cross-sex hormones from puberty blockers is “over 80%.” 

But the actual number of children who are referred to endocrinology services (where puberty blockers are initiated) from GIDS is low, at approximately 16%, according to 2019-2020 data, said a GIDS spokesperson.

“Once at the endocrinology service, young people either participate in a group education session, or if under 15 years, an individualized session between the clinician and the patient and family members,” she added. The Trust also maintained that initiation of cross-sex hormones “is separate from the prescription of puberty blockers.”

Since the December ruling, The Trust has put in place multidisciplinary clinical reviews (MDCR) of cases, and in July, NHS England will start implementing an independent multidisciplinary professional review (MDPR) to check that the GIDS has followed due process with each case.
 

Slow the process down, give appropriate psychotherapy

Stella O’Malley is a psychotherapist who works with transitioners and detransitioners and is a founding member of the International Association of Therapists for Desisters and Detransitioners (IATDD).

Whatever the outcome of the appeal process, Ms. O’Malley said she would like to see the Tavistock slow down and take a broader approach to counseling children before referral to endocrinology services. 

In discussing therapy prior to transition, Ms. O’Malley stated that her clients often say they did not explore their inner motivations or other possible reasons for their distress, and the therapy was focused more on when they transition, rather than being sure it was something they wanted to do.

“We need to learn from the mistakes made with people like Keira Bell. Clinicians need to realize that fast-tracking counseling doesn’t work, especially when [children are] ... young and especially when they’re traumatized,” Ms. O’Malley said.

“Had they received a more conventional therapy, they might have thought about their decision from different perspectives and in the process acquired more self-awareness, which would have been more beneficial.” 

“The ‘affirmative’ approach to gender therapy is too narrow; we need to look at the whole individual. Therapy in other areas would never disregard other, nongender issues such as attention deficit hyperactivity disorder or anxiety [which often co-exist with gender dysphoria] – issues bleed into each other,” Ms. O’Malley pointed out. “We need a more exploratory approach.”  

“I’d also like to see other therapists all over the [U.K.] who are perfectly qualified and capable of working with gender actually start working with gender issues,” she said, noting that such an approach might also help reduce the long waiting list at the Tavistock.

The latter had been overwhelmed, and this led to a speeding up of the assessment process, which led to a number of professionals resigning from the service in recent years, saying children were being “fast-tracked” to medical transition.  
 

Fertility and sexual function are complex issues for kids

Also asked to comment was Claire Graham, from Genspect, a group that describes itself as a voice for parents of gender-questioning kids.

She told this news organization that “parents are rightly concerned about their children’s ability to consent to treatments that may lead to infertility and issues surrounding sexual function.” She added that other countries in Europe were changing their approach. “Look to Sweden and Finland, who have both rowed back on puberty blockers and no longer recommend them.”

Ms. Graham, who has worked with children with differences in sexual development, added that it was very difficult for children and young people to understand the life-long implications of decisions made at an early age.

“How can children understand what it is to live with impaired sexual functioning if they have never had sex? Likewise, fertility is a complex issue. Most people do not want to become parents as teenagers, but we understand that this will often change as they grow,” said Ms. Graham.

“Many parents worry that their child is not being considered in the whole [and] that their child’s ability to consent to medical interventions for gender dysphoria is impacted by comorbidities, such as a diagnosis of autism or a history of mental health issues. These children are particularly vulnerable.”

“At Genspect, we hope that the decision from the ... court is upheld,” Ms. Graham concluded.

A version of this article first appeared on Medscape.com.

Young people with gender dysphoria should be considered as individuals rather than fall into an age-defined bracket when assessing their understanding to consent to hormone treatment, according to the Tavistock and Portman NHS Foundation Trust, as it awaits the verdict of its recent appeal in London against a High Court ruling. 

The High Court ruling, made in December 2020 as reported by this news organization, stated that adolescents with gender dysphoria were unlikely to fully understand the consequences of hormone treatment for gender reassignment and was the result of a case brought by 24-year-old Keira Bell, who transitioned from female to male at the Gender Identity Development Service (GIDS), starting at the age of 16, but later “detransitioned.”

Along with changes made to rules around prescribing puberty blockers and cross-sex hormones to minors with gender dysphoria in countries such as Finland and Sweden, the English ruling signals a more cautious approach to any medical treatment for such children, as detailed in a feature published in April.

However, during the appeal, The Trust argued once more that puberty blockers give children time to “consider options” about their bodies and that the decision (the December ruling) was inconsistent with the law that “entitles children under the age of 16 to make decisions for themselves after being assessed as competent to do so by their doctor.”

Alongside other organizations, the United States–based Endocrine Society submitted written evidence in support of the Tavistock. “The High Court’s decision, if it is allowed to stand, would set a harmful precedent preventing physicians from providing transgender and gender diverse youth with high-quality medical care,” it noted in a statement.

Defending the High Court’s ruling, the lawyer for Ms. Bell said its conclusion was that puberty blockers for gender dysphoria are an “experimental” treatment with a very limited evidence base.

“The judgment of the [High Court] is entirely correct, and there is no proper basis for overturning it,” he asserted.

The 2-day appeal hearing ended on June 24, and a ruling will be made at a later date.
 

Do children understand the consequences of hormone treatment?

One central aspect of the overall case is the fact that Ms. Bell regrets her decision to transition at age 16, saying she only received three counseling sessions prior to endocrinology referral. And she consequently had a mastectomy at age 20, which she also bitterly regrets.

So a key concern is whether young people fully understand the consequences of taking puberty blockers and therapies that may follow, including cross-sex hormones.

Witness for the appeal Gary Butler, MD, consultant in pediatric and adolescent endocrinology at University College Hospital, London, where children are referred to from GIDS for hormone treatment, said the number of children who go on to cross-sex hormones from puberty blockers is “over 80%.” 

But the actual number of children who are referred to endocrinology services (where puberty blockers are initiated) from GIDS is low, at approximately 16%, according to 2019-2020 data, said a GIDS spokesperson.

“Once at the endocrinology service, young people either participate in a group education session, or if under 15 years, an individualized session between the clinician and the patient and family members,” she added. The Trust also maintained that initiation of cross-sex hormones “is separate from the prescription of puberty blockers.”

Since the December ruling, The Trust has put in place multidisciplinary clinical reviews (MDCR) of cases, and in July, NHS England will start implementing an independent multidisciplinary professional review (MDPR) to check that the GIDS has followed due process with each case.
 

Slow the process down, give appropriate psychotherapy

Stella O’Malley is a psychotherapist who works with transitioners and detransitioners and is a founding member of the International Association of Therapists for Desisters and Detransitioners (IATDD).

Whatever the outcome of the appeal process, Ms. O’Malley said she would like to see the Tavistock slow down and take a broader approach to counseling children before referral to endocrinology services. 

In discussing therapy prior to transition, Ms. O’Malley stated that her clients often say they did not explore their inner motivations or other possible reasons for their distress, and the therapy was focused more on when they transition, rather than being sure it was something they wanted to do.

“We need to learn from the mistakes made with people like Keira Bell. Clinicians need to realize that fast-tracking counseling doesn’t work, especially when [children are] ... young and especially when they’re traumatized,” Ms. O’Malley said.

“Had they received a more conventional therapy, they might have thought about their decision from different perspectives and in the process acquired more self-awareness, which would have been more beneficial.” 

“The ‘affirmative’ approach to gender therapy is too narrow; we need to look at the whole individual. Therapy in other areas would never disregard other, nongender issues such as attention deficit hyperactivity disorder or anxiety [which often co-exist with gender dysphoria] – issues bleed into each other,” Ms. O’Malley pointed out. “We need a more exploratory approach.”  

“I’d also like to see other therapists all over the [U.K.] who are perfectly qualified and capable of working with gender actually start working with gender issues,” she said, noting that such an approach might also help reduce the long waiting list at the Tavistock.

The latter had been overwhelmed, and this led to a speeding up of the assessment process, which led to a number of professionals resigning from the service in recent years, saying children were being “fast-tracked” to medical transition.  
 

Fertility and sexual function are complex issues for kids

Also asked to comment was Claire Graham, from Genspect, a group that describes itself as a voice for parents of gender-questioning kids.

She told this news organization that “parents are rightly concerned about their children’s ability to consent to treatments that may lead to infertility and issues surrounding sexual function.” She added that other countries in Europe were changing their approach. “Look to Sweden and Finland, who have both rowed back on puberty blockers and no longer recommend them.”

Ms. Graham, who has worked with children with differences in sexual development, added that it was very difficult for children and young people to understand the life-long implications of decisions made at an early age.

“How can children understand what it is to live with impaired sexual functioning if they have never had sex? Likewise, fertility is a complex issue. Most people do not want to become parents as teenagers, but we understand that this will often change as they grow,” said Ms. Graham.

“Many parents worry that their child is not being considered in the whole [and] that their child’s ability to consent to medical interventions for gender dysphoria is impacted by comorbidities, such as a diagnosis of autism or a history of mental health issues. These children are particularly vulnerable.”

“At Genspect, we hope that the decision from the ... court is upheld,” Ms. Graham concluded.

A version of this article first appeared on Medscape.com.

Young people with gender dysphoria should be considered as individuals rather than fall into an age-defined bracket when assessing their understanding to consent to hormone treatment, according to the Tavistock and Portman NHS Foundation Trust, as it awaits the verdict of its recent appeal in London against a High Court ruling. 

The High Court ruling, made in December 2020 as reported by this news organization, stated that adolescents with gender dysphoria were unlikely to fully understand the consequences of hormone treatment for gender reassignment and was the result of a case brought by 24-year-old Keira Bell, who transitioned from female to male at the Gender Identity Development Service (GIDS), starting at the age of 16, but later “detransitioned.”

Along with changes made to rules around prescribing puberty blockers and cross-sex hormones to minors with gender dysphoria in countries such as Finland and Sweden, the English ruling signals a more cautious approach to any medical treatment for such children, as detailed in a feature published in April.

However, during the appeal, The Trust argued once more that puberty blockers give children time to “consider options” about their bodies and that the decision (the December ruling) was inconsistent with the law that “entitles children under the age of 16 to make decisions for themselves after being assessed as competent to do so by their doctor.”

Alongside other organizations, the United States–based Endocrine Society submitted written evidence in support of the Tavistock. “The High Court’s decision, if it is allowed to stand, would set a harmful precedent preventing physicians from providing transgender and gender diverse youth with high-quality medical care,” it noted in a statement.

Defending the High Court’s ruling, the lawyer for Ms. Bell said its conclusion was that puberty blockers for gender dysphoria are an “experimental” treatment with a very limited evidence base.

“The judgment of the [High Court] is entirely correct, and there is no proper basis for overturning it,” he asserted.

The 2-day appeal hearing ended on June 24, and a ruling will be made at a later date.
 

Do children understand the consequences of hormone treatment?

One central aspect of the overall case is the fact that Ms. Bell regrets her decision to transition at age 16, saying she only received three counseling sessions prior to endocrinology referral. And she consequently had a mastectomy at age 20, which she also bitterly regrets.

So a key concern is whether young people fully understand the consequences of taking puberty blockers and therapies that may follow, including cross-sex hormones.

Witness for the appeal Gary Butler, MD, consultant in pediatric and adolescent endocrinology at University College Hospital, London, where children are referred to from GIDS for hormone treatment, said the number of children who go on to cross-sex hormones from puberty blockers is “over 80%.” 

But the actual number of children who are referred to endocrinology services (where puberty blockers are initiated) from GIDS is low, at approximately 16%, according to 2019-2020 data, said a GIDS spokesperson.

“Once at the endocrinology service, young people either participate in a group education session, or if under 15 years, an individualized session between the clinician and the patient and family members,” she added. The Trust also maintained that initiation of cross-sex hormones “is separate from the prescription of puberty blockers.”

Since the December ruling, The Trust has put in place multidisciplinary clinical reviews (MDCR) of cases, and in July, NHS England will start implementing an independent multidisciplinary professional review (MDPR) to check that the GIDS has followed due process with each case.
 

Slow the process down, give appropriate psychotherapy

Stella O’Malley is a psychotherapist who works with transitioners and detransitioners and is a founding member of the International Association of Therapists for Desisters and Detransitioners (IATDD).

Whatever the outcome of the appeal process, Ms. O’Malley said she would like to see the Tavistock slow down and take a broader approach to counseling children before referral to endocrinology services. 

In discussing therapy prior to transition, Ms. O’Malley stated that her clients often say they did not explore their inner motivations or other possible reasons for their distress, and the therapy was focused more on when they transition, rather than being sure it was something they wanted to do.

“We need to learn from the mistakes made with people like Keira Bell. Clinicians need to realize that fast-tracking counseling doesn’t work, especially when [children are] ... young and especially when they’re traumatized,” Ms. O’Malley said.

“Had they received a more conventional therapy, they might have thought about their decision from different perspectives and in the process acquired more self-awareness, which would have been more beneficial.” 

“The ‘affirmative’ approach to gender therapy is too narrow; we need to look at the whole individual. Therapy in other areas would never disregard other, nongender issues such as attention deficit hyperactivity disorder or anxiety [which often co-exist with gender dysphoria] – issues bleed into each other,” Ms. O’Malley pointed out. “We need a more exploratory approach.”  

“I’d also like to see other therapists all over the [U.K.] who are perfectly qualified and capable of working with gender actually start working with gender issues,” she said, noting that such an approach might also help reduce the long waiting list at the Tavistock.

The latter had been overwhelmed, and this led to a speeding up of the assessment process, which led to a number of professionals resigning from the service in recent years, saying children were being “fast-tracked” to medical transition.  
 

Fertility and sexual function are complex issues for kids

Also asked to comment was Claire Graham, from Genspect, a group that describes itself as a voice for parents of gender-questioning kids.

She told this news organization that “parents are rightly concerned about their children’s ability to consent to treatments that may lead to infertility and issues surrounding sexual function.” She added that other countries in Europe were changing their approach. “Look to Sweden and Finland, who have both rowed back on puberty blockers and no longer recommend them.”

Ms. Graham, who has worked with children with differences in sexual development, added that it was very difficult for children and young people to understand the life-long implications of decisions made at an early age.

“How can children understand what it is to live with impaired sexual functioning if they have never had sex? Likewise, fertility is a complex issue. Most people do not want to become parents as teenagers, but we understand that this will often change as they grow,” said Ms. Graham.

“Many parents worry that their child is not being considered in the whole [and] that their child’s ability to consent to medical interventions for gender dysphoria is impacted by comorbidities, such as a diagnosis of autism or a history of mental health issues. These children are particularly vulnerable.”

“At Genspect, we hope that the decision from the ... court is upheld,” Ms. Graham concluded.

A version of this article first appeared on Medscape.com.

Researchers have discovered a new dopaminergic neural circuit leading to the hindbrain that is involved in satiety (feeling full and eating cessation) in mice, which may eventually lead to new ways to treat obesity.

Moreover, when mice were given methylphenidate (Ritalin, Concerta) – a stimulant approved to treat attention deficit hyperactivity disorder (ADHD) with a well-known side effect of decreasing appetite – signals in this dopaminergic pathway were enhanced and the mice ate less.

The study by Yong Han, PhD, a postdoctoral associate at Baylor College of Medicine, Houston, and colleagues was published online May 27 in Science Advances.

“We identified a new dopamine neural circuit from the midbrain to the hindbrain (brainstem) that regulates feeding behavior through an enhanced satiation response,” senior author Qi Wu, PhD, assistant professor in pediatrics-nutrition at Baylor College of Medicine, summarized in an interview.

The findings suggest that “people with obesity have a compromised dopaminergic neural pathway, presumably in ways that delay the satiation response, which makes them eat more, have a larger meal,” he explained.
 

Newly identified brain circuit plays a key role in satiety response

The study is about a circuit in the brain that helps precisely regulate the size of food portion consumed, Dr. Wu emphasized in a statement from the university, adding that the satiation response is as important as appetite.

Importantly, the results also provide clues about how methylphenidate can lead to weight loss.  

Regulators have deemed that methylphenidate, a controlled substance with other side effects such as anxiety and a fast heart rate, is safe and effective for ADHD, Dr. Wu noted.

He speculated that, “If researchers want to do clinical trials of methylphenidate for obesity, it ultimately could evolve to be an anti-obesity drug, alone or combined with other drugs, or possibly derivatives of methylphenidate could be tested.”

The brain circuit “we discovered is the first to be fully described to regulate portion size via dopamine signaling,” Dr. Han stressed in the statement.

“Our new study shows that a circuit connecting neurons that produce dopamine, a chemical messenger previously known for the regulation of motivation and pleasure, has a new [critical] role in the control of feeding through dynamically regulating the satiety response,” he explained.
 

Brain signals that control portion size 

Earlier studies that investigated how the dopaminergic system may regulate food intake, appetite, and body weight, have produced conflicting results, Dr. Wu said.

The researchers performed several experiments in mice that included the use of cell-specific circuitry mapping, optogenetics, and real-time recordings of brain activity.

They identified a new dopaminergic neural circuit comprised of dopaminergic neurons in the caudal ventral tegmental area (DA-VTA neurons) in the midbrain that directly innervate dopamine receptor D1-expressing neurons within the lateral parabrachial nucleus (DRD1-LPBN neurons) in the hindbrain.

There were four main findings:

• DA-VTA neurons were activated immediately before the cessation of each feeding bout.
• Actively inhibiting DA-VTA neurons before the end of each feeding bout prolonged the feeding.
• Activating DRD1-LPBN neurons inhibited feeding.
• Mice that lacked the DRD1 gene ate much more and gained weight.

“Our study illuminates a hindbrain dopaminergic circuit that controls feeding through dynamic regulation in satiety response and meal structure,” the researchers reiterate.

The study was supported by grants from the National Institutes of Health, NIH Digestive Diseases Center, Pew Charitable Trust, American Diabetes Association, Baylor Collaborative Faculty Research Investment Program, USDA/CRIS, USDA/ARS, American Heart Association, and NIH Centers of Biomedical Research Excellence, and by Pew and Kavli scholarships. The researchers have reported no relevant financial disclosures. 

A version of this article first appeared on Medscape.com.

Researchers have discovered a new dopaminergic neural circuit leading to the hindbrain that is involved in satiety (feeling full and eating cessation) in mice, which may eventually lead to new ways to treat obesity.

Moreover, when mice were given methylphenidate (Ritalin, Concerta) – a stimulant approved to treat attention deficit hyperactivity disorder (ADHD) with a well-known side effect of decreasing appetite – signals in this dopaminergic pathway were enhanced and the mice ate less.

The study by Yong Han, PhD, a postdoctoral associate at Baylor College of Medicine, Houston, and colleagues was published online May 27 in Science Advances.

“We identified a new dopamine neural circuit from the midbrain to the hindbrain (brainstem) that regulates feeding behavior through an enhanced satiation response,” senior author Qi Wu, PhD, assistant professor in pediatrics-nutrition at Baylor College of Medicine, summarized in an interview.

The findings suggest that “people with obesity have a compromised dopaminergic neural pathway, presumably in ways that delay the satiation response, which makes them eat more, have a larger meal,” he explained.
 

Newly identified brain circuit plays a key role in satiety response

The study is about a circuit in the brain that helps precisely regulate the size of food portion consumed, Dr. Wu emphasized in a statement from the university, adding that the satiation response is as important as appetite.

Importantly, the results also provide clues about how methylphenidate can lead to weight loss.  

Regulators have deemed that methylphenidate, a controlled substance with other side effects such as anxiety and a fast heart rate, is safe and effective for ADHD, Dr. Wu noted.

He speculated that, “If researchers want to do clinical trials of methylphenidate for obesity, it ultimately could evolve to be an anti-obesity drug, alone or combined with other drugs, or possibly derivatives of methylphenidate could be tested.”

The brain circuit “we discovered is the first to be fully described to regulate portion size via dopamine signaling,” Dr. Han stressed in the statement.

“Our new study shows that a circuit connecting neurons that produce dopamine, a chemical messenger previously known for the regulation of motivation and pleasure, has a new [critical] role in the control of feeding through dynamically regulating the satiety response,” he explained.
 

Brain signals that control portion size 

Earlier studies that investigated how the dopaminergic system may regulate food intake, appetite, and body weight, have produced conflicting results, Dr. Wu said.

The researchers performed several experiments in mice that included the use of cell-specific circuitry mapping, optogenetics, and real-time recordings of brain activity.

They identified a new dopaminergic neural circuit comprised of dopaminergic neurons in the caudal ventral tegmental area (DA-VTA neurons) in the midbrain that directly innervate dopamine receptor D1-expressing neurons within the lateral parabrachial nucleus (DRD1-LPBN neurons) in the hindbrain.

There were four main findings:

• DA-VTA neurons were activated immediately before the cessation of each feeding bout.
• Actively inhibiting DA-VTA neurons before the end of each feeding bout prolonged the feeding.
• Activating DRD1-LPBN neurons inhibited feeding.
• Mice that lacked the DRD1 gene ate much more and gained weight.

“Our study illuminates a hindbrain dopaminergic circuit that controls feeding through dynamic regulation in satiety response and meal structure,” the researchers reiterate.

The study was supported by grants from the National Institutes of Health, NIH Digestive Diseases Center, Pew Charitable Trust, American Diabetes Association, Baylor Collaborative Faculty Research Investment Program, USDA/CRIS, USDA/ARS, American Heart Association, and NIH Centers of Biomedical Research Excellence, and by Pew and Kavli scholarships. The researchers have reported no relevant financial disclosures. 

A version of this article first appeared on Medscape.com.

Researchers have discovered a new dopaminergic neural circuit leading to the hindbrain that is involved in satiety (feeling full and eating cessation) in mice, which may eventually lead to new ways to treat obesity.

Moreover, when mice were given methylphenidate (Ritalin, Concerta) – a stimulant approved to treat attention deficit hyperactivity disorder (ADHD) with a well-known side effect of decreasing appetite – signals in this dopaminergic pathway were enhanced and the mice ate less.

The study by Yong Han, PhD, a postdoctoral associate at Baylor College of Medicine, Houston, and colleagues was published online May 27 in Science Advances.

“We identified a new dopamine neural circuit from the midbrain to the hindbrain (brainstem) that regulates feeding behavior through an enhanced satiation response,” senior author Qi Wu, PhD, assistant professor in pediatrics-nutrition at Baylor College of Medicine, summarized in an interview.

The findings suggest that “people with obesity have a compromised dopaminergic neural pathway, presumably in ways that delay the satiation response, which makes them eat more, have a larger meal,” he explained.
 

Newly identified brain circuit plays a key role in satiety response

The study is about a circuit in the brain that helps precisely regulate the size of food portion consumed, Dr. Wu emphasized in a statement from the university, adding that the satiation response is as important as appetite.

Importantly, the results also provide clues about how methylphenidate can lead to weight loss.  

Regulators have deemed that methylphenidate, a controlled substance with other side effects such as anxiety and a fast heart rate, is safe and effective for ADHD, Dr. Wu noted.

He speculated that, “If researchers want to do clinical trials of methylphenidate for obesity, it ultimately could evolve to be an anti-obesity drug, alone or combined with other drugs, or possibly derivatives of methylphenidate could be tested.”

The brain circuit “we discovered is the first to be fully described to regulate portion size via dopamine signaling,” Dr. Han stressed in the statement.

“Our new study shows that a circuit connecting neurons that produce dopamine, a chemical messenger previously known for the regulation of motivation and pleasure, has a new [critical] role in the control of feeding through dynamically regulating the satiety response,” he explained.
 

Brain signals that control portion size 

Earlier studies that investigated how the dopaminergic system may regulate food intake, appetite, and body weight, have produced conflicting results, Dr. Wu said.

The researchers performed several experiments in mice that included the use of cell-specific circuitry mapping, optogenetics, and real-time recordings of brain activity.

They identified a new dopaminergic neural circuit comprised of dopaminergic neurons in the caudal ventral tegmental area (DA-VTA neurons) in the midbrain that directly innervate dopamine receptor D1-expressing neurons within the lateral parabrachial nucleus (DRD1-LPBN neurons) in the hindbrain.

There were four main findings:

• DA-VTA neurons were activated immediately before the cessation of each feeding bout.
• Actively inhibiting DA-VTA neurons before the end of each feeding bout prolonged the feeding.
• Activating DRD1-LPBN neurons inhibited feeding.
• Mice that lacked the DRD1 gene ate much more and gained weight.

“Our study illuminates a hindbrain dopaminergic circuit that controls feeding through dynamic regulation in satiety response and meal structure,” the researchers reiterate.

The study was supported by grants from the National Institutes of Health, NIH Digestive Diseases Center, Pew Charitable Trust, American Diabetes Association, Baylor Collaborative Faculty Research Investment Program, USDA/CRIS, USDA/ARS, American Heart Association, and NIH Centers of Biomedical Research Excellence, and by Pew and Kavli scholarships. The researchers have reported no relevant financial disclosures. 

A version of this article first appeared on Medscape.com.

An innovative text-messaging program that reminds patients with attention-deficit/hyperactivity disorder to take their medication and warns them about the hazards of noncompliance significantly increases treatment adherence in children and adults, new research suggests.

PxHere

In a pediatric study, 85% of participants who received a text message had their prescriptions refilled in a timely manner, compared with 62% of those who received treatment as usual and no text messaging. In a second study of adults, 81% of the group that received a text message refilled their prescriptions, versus 36% of those in the usual-treatment group.

“Patients are not going to be fully compliant if they do not understand what the implications are if they do not take their pills,” lead author Joseph Biederman, MD, chief of clinical and research programs in pediatric psychopharmacology and adult ADHD at the Massachusetts General Hospital and professor of psychiatry at Harvard Medical School, Boston, told this news organization.

He noted that the text-messaging program also provides information, support, encouragement, and guidance.

“We remind them to get in touch with their prescriber as renewals come due, and if they tell us no, we tell them how important it is” to do so, Dr. Biederman said.

The findings were presented at the virtual American Society of Clinical Psychopharmacology 2021 annual meeting.
 

Poor adherence

“Adherence to medications for ADHD is extremely poor, among the worst in medicine, despite the fact that ADHD is very morbid and we have excellent treatments people can take,” Dr. Biederman noted. “That’s the first tragedy, and it is totally unappreciated.”

He added that forgetfulness is a feature of ADHD. In addition, compliance can be difficult and cumbersome when patients require multiple prescriptions, he said.

Another contributor to medication nonadherence is the ongoing prejudice or stigma associated with ADHD, said Dr. Biederman.

“There is bad press about ADHD. There are no good comments, only disaster, doom and gloom, catastrophe, and so on. All people read in the available media are bad things about ADHD, and that only adds to stigma and misinformation,” he noted.

To combat these factors, Dr. Biederman and his team conducted two studies on the effectiveness of a novel ADHD-centric intervention based on text messaging.

One study included 87 children aged 6-12 years, and the other included 117 adults aged 18-55 years. Both groups were from primary care settings and were prescribed a stimulant medication for the treatment of ADHD.

As comparators, the researchers used age- and sex-matched pediatric patients and age-, race-, and sex-matched adult patients from the same primary care settings. They had also been prescribed stimulants but had not received the text messaging intervention.
 

Timely reminders

Results showed that 85% of the children who received text messages refilled their prescriptions vs. 65% of those who did not get the intervention (odds ratio, 3.46; 95% confidence interval, 1.82-6.58; P < .001).

Among adults, 81% of the intervention group refilled their prescriptions vs. 36% of the comparator group (OR, 7.54; 95% CI, 4.46-12.77; P < .001).

“In the number-needed-to-treat analysis, for every five pediatric patients who receive text messaging, we can keep one adherent with stimulant medication. In adults, that is one in every three who receive the text-messaging intervention,” Dr. Biederman said.

Text messaging reminds patients with ADHD to take their medications as prescribed, and it also reminds them of the consequences of not taking their medications, he added.

In another study presented at the ASCP meeting, Dr. Biederman introduced a new tool to help clinicians determine whether a patient with ADHD also has deficient emotional self-regulation (DESR).

ADHD has been associated with low frustration tolerance, impatience, and quickness to anger, he noted.

Emotional dysregulation, however, “is not a mood disorder,” said Dr. Biederman. “Some people use the term ‘hot tempered.’ These are people who overreact to things, and this is associated with a wide range of difficulties.”
 

Clinical guidance

The investigators operationalized DESR using the eight-item Emotional Dysregulation (ED) subscale of the Barkley Current Behavior Scale. They then used receiver operating characteristic curves to identify the optimal cutoff on the Barkley ED Scale that would categorize patients as having high- vs. low-level DESR.

“We wanted to give some guidance to clinicians, using a very simple rating scale that was developed by Dr. Barkley. It is one we think configures this syndrome of emotional dysregulation and emotional impulsivity,” Dr. Biederman said.

The study included 441 newly referred 18- to 55-year-old men and women who met DSM-5 diagnostic criteria for ADHD.

Using a cutoff score of 8 to represent high levels of DESR, the researchers identified 191 adults as having high-level DESR and the rest as having low-level DESR.

Those with high-level DESR had significantly more severe symptoms of ADHD, executive dysfunction, autistic traits, levels of psychopathology, and worse quality of life, compared with those with low-level DESR.

The problem of emotional dysregulation in ADHD is widespread and affects many people, Dr. Biederman noted.

“If you take 5% of adults at a minimum and 10% of children with ADHD [and] if 50% of those have emotional dysregulation, we’re talking about millions of people. And it is very morbid,” he said. “Having emotional dysregulation problems will get you in hot water.”
 

Promising results

Commenting on the findings for this news organization, Ira D. Glick, MD, professor emeritus of psychiatry and behavioral sciences, Stanford (Calif.) University, said the new studies are important.

He noted that, although ADHD has become more accepted as a “disease of the brain” over the past 20 years, patients with the disorder and their families often are not accepting of the diagnosis.

“Instead, they try to downplay it. They say this is just a ploy by psychiatrists to get business or this is just normal boys’ behavior, [and] they don’t need medicines,” said Dr. Glick, who was not involved in the current research.

“Biederman is trying to make clear that ADHD is a brain disease, and DESR symptoms are cardinal signs of a brain illness,” he said.

Dr. Glick also agreed that text messaging could be very useful for these patients.

“Text messaging might be helpful, especially in this population which can often be disorganized or forgetful. The results of that study were very promising,” he said.

Dr. Biederman is in the process of commercializing the text program used in the study. Dr. Glick reports no relevant financial relationships.

A version of this article first appeared on Medscape.com.

An innovative text-messaging program that reminds patients with attention-deficit/hyperactivity disorder to take their medication and warns them about the hazards of noncompliance significantly increases treatment adherence in children and adults, new research suggests.

PxHere

In a pediatric study, 85% of participants who received a text message had their prescriptions refilled in a timely manner, compared with 62% of those who received treatment as usual and no text messaging. In a second study of adults, 81% of the group that received a text message refilled their prescriptions, versus 36% of those in the usual-treatment group.

“Patients are not going to be fully compliant if they do not understand what the implications are if they do not take their pills,” lead author Joseph Biederman, MD, chief of clinical and research programs in pediatric psychopharmacology and adult ADHD at the Massachusetts General Hospital and professor of psychiatry at Harvard Medical School, Boston, told this news organization.

He noted that the text-messaging program also provides information, support, encouragement, and guidance.

“We remind them to get in touch with their prescriber as renewals come due, and if they tell us no, we tell them how important it is” to do so, Dr. Biederman said.

The findings were presented at the virtual American Society of Clinical Psychopharmacology 2021 annual meeting.
 

Poor adherence

“Adherence to medications for ADHD is extremely poor, among the worst in medicine, despite the fact that ADHD is very morbid and we have excellent treatments people can take,” Dr. Biederman noted. “That’s the first tragedy, and it is totally unappreciated.”

He added that forgetfulness is a feature of ADHD. In addition, compliance can be difficult and cumbersome when patients require multiple prescriptions, he said.

Another contributor to medication nonadherence is the ongoing prejudice or stigma associated with ADHD, said Dr. Biederman.

“There is bad press about ADHD. There are no good comments, only disaster, doom and gloom, catastrophe, and so on. All people read in the available media are bad things about ADHD, and that only adds to stigma and misinformation,” he noted.

To combat these factors, Dr. Biederman and his team conducted two studies on the effectiveness of a novel ADHD-centric intervention based on text messaging.

One study included 87 children aged 6-12 years, and the other included 117 adults aged 18-55 years. Both groups were from primary care settings and were prescribed a stimulant medication for the treatment of ADHD.

As comparators, the researchers used age- and sex-matched pediatric patients and age-, race-, and sex-matched adult patients from the same primary care settings. They had also been prescribed stimulants but had not received the text messaging intervention.
 

Timely reminders

Results showed that 85% of the children who received text messages refilled their prescriptions vs. 65% of those who did not get the intervention (odds ratio, 3.46; 95% confidence interval, 1.82-6.58; P < .001).

Among adults, 81% of the intervention group refilled their prescriptions vs. 36% of the comparator group (OR, 7.54; 95% CI, 4.46-12.77; P < .001).

“In the number-needed-to-treat analysis, for every five pediatric patients who receive text messaging, we can keep one adherent with stimulant medication. In adults, that is one in every three who receive the text-messaging intervention,” Dr. Biederman said.

Text messaging reminds patients with ADHD to take their medications as prescribed, and it also reminds them of the consequences of not taking their medications, he added.

In another study presented at the ASCP meeting, Dr. Biederman introduced a new tool to help clinicians determine whether a patient with ADHD also has deficient emotional self-regulation (DESR).

ADHD has been associated with low frustration tolerance, impatience, and quickness to anger, he noted.

Emotional dysregulation, however, “is not a mood disorder,” said Dr. Biederman. “Some people use the term ‘hot tempered.’ These are people who overreact to things, and this is associated with a wide range of difficulties.”
 

Clinical guidance

The investigators operationalized DESR using the eight-item Emotional Dysregulation (ED) subscale of the Barkley Current Behavior Scale. They then used receiver operating characteristic curves to identify the optimal cutoff on the Barkley ED Scale that would categorize patients as having high- vs. low-level DESR.

“We wanted to give some guidance to clinicians, using a very simple rating scale that was developed by Dr. Barkley. It is one we think configures this syndrome of emotional dysregulation and emotional impulsivity,” Dr. Biederman said.

The study included 441 newly referred 18- to 55-year-old men and women who met DSM-5 diagnostic criteria for ADHD.

Using a cutoff score of 8 to represent high levels of DESR, the researchers identified 191 adults as having high-level DESR and the rest as having low-level DESR.

Those with high-level DESR had significantly more severe symptoms of ADHD, executive dysfunction, autistic traits, levels of psychopathology, and worse quality of life, compared with those with low-level DESR.

The problem of emotional dysregulation in ADHD is widespread and affects many people, Dr. Biederman noted.

“If you take 5% of adults at a minimum and 10% of children with ADHD [and] if 50% of those have emotional dysregulation, we’re talking about millions of people. And it is very morbid,” he said. “Having emotional dysregulation problems will get you in hot water.”
 

Promising results

Commenting on the findings for this news organization, Ira D. Glick, MD, professor emeritus of psychiatry and behavioral sciences, Stanford (Calif.) University, said the new studies are important.

He noted that, although ADHD has become more accepted as a “disease of the brain” over the past 20 years, patients with the disorder and their families often are not accepting of the diagnosis.

“Instead, they try to downplay it. They say this is just a ploy by psychiatrists to get business or this is just normal boys’ behavior, [and] they don’t need medicines,” said Dr. Glick, who was not involved in the current research.

“Biederman is trying to make clear that ADHD is a brain disease, and DESR symptoms are cardinal signs of a brain illness,” he said.

Dr. Glick also agreed that text messaging could be very useful for these patients.

“Text messaging might be helpful, especially in this population which can often be disorganized or forgetful. The results of that study were very promising,” he said.

Dr. Biederman is in the process of commercializing the text program used in the study. Dr. Glick reports no relevant financial relationships.

A version of this article first appeared on Medscape.com.

An innovative text-messaging program that reminds patients with attention-deficit/hyperactivity disorder to take their medication and warns them about the hazards of noncompliance significantly increases treatment adherence in children and adults, new research suggests.

PxHere

In a pediatric study, 85% of participants who received a text message had their prescriptions refilled in a timely manner, compared with 62% of those who received treatment as usual and no text messaging. In a second study of adults, 81% of the group that received a text message refilled their prescriptions, versus 36% of those in the usual-treatment group.

“Patients are not going to be fully compliant if they do not understand what the implications are if they do not take their pills,” lead author Joseph Biederman, MD, chief of clinical and research programs in pediatric psychopharmacology and adult ADHD at the Massachusetts General Hospital and professor of psychiatry at Harvard Medical School, Boston, told this news organization.

He noted that the text-messaging program also provides information, support, encouragement, and guidance.

“We remind them to get in touch with their prescriber as renewals come due, and if they tell us no, we tell them how important it is” to do so, Dr. Biederman said.

The findings were presented at the virtual American Society of Clinical Psychopharmacology 2021 annual meeting.
 

Poor adherence

“Adherence to medications for ADHD is extremely poor, among the worst in medicine, despite the fact that ADHD is very morbid and we have excellent treatments people can take,” Dr. Biederman noted. “That’s the first tragedy, and it is totally unappreciated.”

He added that forgetfulness is a feature of ADHD. In addition, compliance can be difficult and cumbersome when patients require multiple prescriptions, he said.

Another contributor to medication nonadherence is the ongoing prejudice or stigma associated with ADHD, said Dr. Biederman.

“There is bad press about ADHD. There are no good comments, only disaster, doom and gloom, catastrophe, and so on. All people read in the available media are bad things about ADHD, and that only adds to stigma and misinformation,” he noted.

To combat these factors, Dr. Biederman and his team conducted two studies on the effectiveness of a novel ADHD-centric intervention based on text messaging.

One study included 87 children aged 6-12 years, and the other included 117 adults aged 18-55 years. Both groups were from primary care settings and were prescribed a stimulant medication for the treatment of ADHD.

As comparators, the researchers used age- and sex-matched pediatric patients and age-, race-, and sex-matched adult patients from the same primary care settings. They had also been prescribed stimulants but had not received the text messaging intervention.
 

Timely reminders

Results showed that 85% of the children who received text messages refilled their prescriptions vs. 65% of those who did not get the intervention (odds ratio, 3.46; 95% confidence interval, 1.82-6.58; P < .001).

Among adults, 81% of the intervention group refilled their prescriptions vs. 36% of the comparator group (OR, 7.54; 95% CI, 4.46-12.77; P < .001).

“In the number-needed-to-treat analysis, for every five pediatric patients who receive text messaging, we can keep one adherent with stimulant medication. In adults, that is one in every three who receive the text-messaging intervention,” Dr. Biederman said.

Text messaging reminds patients with ADHD to take their medications as prescribed, and it also reminds them of the consequences of not taking their medications, he added.

In another study presented at the ASCP meeting, Dr. Biederman introduced a new tool to help clinicians determine whether a patient with ADHD also has deficient emotional self-regulation (DESR).

ADHD has been associated with low frustration tolerance, impatience, and quickness to anger, he noted.

Emotional dysregulation, however, “is not a mood disorder,” said Dr. Biederman. “Some people use the term ‘hot tempered.’ These are people who overreact to things, and this is associated with a wide range of difficulties.”
 

Clinical guidance

The investigators operationalized DESR using the eight-item Emotional Dysregulation (ED) subscale of the Barkley Current Behavior Scale. They then used receiver operating characteristic curves to identify the optimal cutoff on the Barkley ED Scale that would categorize patients as having high- vs. low-level DESR.

“We wanted to give some guidance to clinicians, using a very simple rating scale that was developed by Dr. Barkley. It is one we think configures this syndrome of emotional dysregulation and emotional impulsivity,” Dr. Biederman said.

The study included 441 newly referred 18- to 55-year-old men and women who met DSM-5 diagnostic criteria for ADHD.

Using a cutoff score of 8 to represent high levels of DESR, the researchers identified 191 adults as having high-level DESR and the rest as having low-level DESR.

Those with high-level DESR had significantly more severe symptoms of ADHD, executive dysfunction, autistic traits, levels of psychopathology, and worse quality of life, compared with those with low-level DESR.

The problem of emotional dysregulation in ADHD is widespread and affects many people, Dr. Biederman noted.

“If you take 5% of adults at a minimum and 10% of children with ADHD [and] if 50% of those have emotional dysregulation, we’re talking about millions of people. And it is very morbid,” he said. “Having emotional dysregulation problems will get you in hot water.”
 

Promising results

Commenting on the findings for this news organization, Ira D. Glick, MD, professor emeritus of psychiatry and behavioral sciences, Stanford (Calif.) University, said the new studies are important.

He noted that, although ADHD has become more accepted as a “disease of the brain” over the past 20 years, patients with the disorder and their families often are not accepting of the diagnosis.

“Instead, they try to downplay it. They say this is just a ploy by psychiatrists to get business or this is just normal boys’ behavior, [and] they don’t need medicines,” said Dr. Glick, who was not involved in the current research.

“Biederman is trying to make clear that ADHD is a brain disease, and DESR symptoms are cardinal signs of a brain illness,” he said.

Dr. Glick also agreed that text messaging could be very useful for these patients.

“Text messaging might be helpful, especially in this population which can often be disorganized or forgetful. The results of that study were very promising,” he said.

Dr. Biederman is in the process of commercializing the text program used in the study. Dr. Glick reports no relevant financial relationships.

A version of this article first appeared on Medscape.com.