Professor Jan Buitelaar
NeuroIMAGE – Findings from a large prospective ADHD case-control study
In the opening plenary session, Professor Jan Buitelaar (Radboudumc & Karakter Child and Adolescent Psychiatry, Nijmegen, The Netherlands) reported findings from the Dutch part of the International Multicenter ADHD (IMAGE) study. The persistence of ADHD was highlighted, with over 80% of the initial cohort of children with combined subtype ADHD still showing symptoms at the 6-year follow-up.1
Professor Buitelaar then went on to discuss findings from magnetic resonance image (MRI) analyses, which showed several key differences in brain structure between children with and without ADHD; in particular, that children with ADHD showed persistently smaller total brain and grey matter volumes compared with controls.2 Professor Buitelaar concluded with the findings that symptoms of inattention appear to drive symptoms of hyperactivity and impulsivity, and not vice versa.
Professor Buitelaar: “Perhaps the most interesting findings were the link between inattention and impulsivity. Inattention is driving hyperactivity/impulsivity and not the other way around.”
“Inattention is the key symptom, driving differences in hyperactivity/impulsivity. This would really suggest that interventions that affect inattention would have forward effects on hyperactivity/impulsivity.”
Professor Philip Asherson
Mind wandering, a new perspective on attentional problems in ADHD
Professor Philip Asherson (MRC Social, Genetic and Developmental Psychiatry [SGDP] Research Centre at the Institute of Psychiatry, King’s College, London, UK) provided a detailed overview of mind wandering as a symptom of ADHD. Using emotive patient videos, Professor Asherson demonstrated the measurable difficulties that mind wandering may cause for patients with ADHD in performing tasks, sleeping, showing self-awareness and controlling behaviour.
The 15-item Mind Excessively Wandering Scale (MEWS), developed by Professor Asherson’s research group, to reflect mind wandering in ADHD derived from patient reports of subjective experiences of their thought processes was described.3
This was followed by a discussion of future perspectives including further validation of the scale, case-control studies to investigate neural activity during mind wandering and the effect of pharmacological therapy on mind wandering.
Professor Asherson: “You’ve got all these volumes and they’re on full all of the time…it’s disorganised, chaotic and hectic.”
Patient: “It’s a cacophony of ideas…layers and layers of stuff going on. It can wake me up at night. Just this internal dialogue going on and on. I can’t stop it.”
Potential long-term adverse effects of stimulant medication (results from the ADDUCE consortium)
In the first symposium, chaired by Professor Tobias Banaschewski (Child & Adolescent Psychiatry, University of Heidelberg, Mannheim, Germany), the audience were introduced to preliminary unpublished results from the Attention Deficit Hyperactivity Disorder Drugs Use Chronic Effects (ADDUCE) study, which investigated the long-term safety of methylphenidate in children with ADHD.4
Professor Alessandro Zuddas (Child and Adolescent Neuropsychiatry Unity, Department of Biological Sciences, University of Cagliari, Sardinia, Italy) provided a brief overview of the ADDUCE study, before Dr Sara Carucci (Child and Adolescent Neuropsychiatry Unit, Department of Biological Science, University of Cagliari, Sardinia, Italy) presented evidence suggesting that methylphenidate has a significant negative effect on weight and height velocity, with no effect on pubertal maturation.5 Dr Elizabeth Liddle (Faculty of Medicine and Health Sciences, University of Nottingham, UK) discussed adverse psychiatric effects, concluding that there were no direct links with methylphenidate.5
Finally, Professor David Coghill (Departments of Paediatrics and Psychiatry, University of Melbourne, Royal Children’s Hospital, Melbourne, Australia) discussed the long-term effects of methylphenidate on cardiovascular risk and the clinical implications.5
Dr Liddle: “The striking finding is how much ADHD is associated with adverse psychiatric outcomes.”
Professor Coghill: “The finding of no differences in evening and night-time heart rate and blood pressure values suggests that these are direct pharmacological effects…that’s actually a lot less worrying.”
Professor Coghill: “The bottom line is that it’s still very important to monitor adverse events carefully.”
In the second symposium of the day, Professor Cesar Soutullo (Child and Adolescent Psychiatry Unit, University of Navarra Clinic, Pamplona, Spain) explained the barriers that patients with ADHD can experience in transitioning from adolescence into adulthood.
Dr Henrik Larsson (Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm) then discussed his previous research from Swedish National Registers, which showed that the increased risk of suicide in adults with ADHD can only partially be explained by comorbidities.6
Dr Alexandra Philipsen (Department of Psychiatry and Psychotherapy, University Medical Centre, Freiburg, Germany) continued by exploring the efficacy of different psychological interventions, including group psychotherapy, with and without pharmacological therapy in results from the Comparison of Methylphenidate and Psychotherapy in Adult ADHD Study (COMPAS).
Finally, Dr Samuel Cortese (Psychology Department, University of Southampton, UK) stressed the significant association between ADHD and obesity,7,8 and highlighted that it is just one of the associations that are altering our overall understanding of ADHD.
Professor Soutullo: “This is what I call the non-emancipated adult…they are not yet able to function as an adult and they need a lot of help and support.”
Professor Emily Simonoff
Professor Saskia van der Oord
Europe got it wrong! Medication should always be first-line treatment for ADHD
In this spirited and divisive debate, Professor Emily Simonoff (Department of Child and Adolescent Psychiatry, King’s College London, UK) argued in favour of the motion that medication should always be the first-line treatment for ADHD.
Professor Simonoff argued that an attitude of “behavioural therapies might not do anything, but they won’t do you any harm” would not be accepted in the treatment of a physical illness. Professor Saskia van der Oord (KU Leuven, Belgium, and the University of Amsterdam, The Netherlands) provided a light-hearted rebuttal, arguing that behavioural therapies can target impairments experienced in everyday life, which will have more meaning to patients and parents compared with an effect on the symptoms of ADHD.
An enthusiastic audience then participated in the debate, questioning how the severity of ADHD, the age of the patient and regional differences in access to behavioural therapy would affect treatment plans. Both sides of the argument were convincing, with the audience vote at the end of the debate split equally for and against the motion.
Professor Simonoff: “I want you to start by asking yourselves why we have a different gold standard for psychiatric disorders? Would patients and clinicians accept an ineffective treatment for a physical condition?”
Professor van der Oord: “Pills don’t teach skills and behaviour therapy does.”
Professor David Coghill interviewing Professor Sir Joseph Sergeant and Professor Eric Taylor
EUNETHYDIS @ 30: An interview with Joe Sergeant and Eric Taylor
The day came to a close with a special session in which the key founders of EUNETHYDIS, Professor Sir Joseph Sergeant (Professor Emeritus of Clinical Neuropsychology, Vrije University, Amsterdam, The Netherlands) and Professor Eric Taylor (Department of Child and Adolescent Psychiatry, King’s College London, UK), were interviewed by Professor David Coghill (Departments of Pediatrics and Psychiatry, University of Melbourne Royal Children’s Hospital, Melbourne, Australia).
Professor Taylor shared the difficulties he experienced as a clinician in the late 1970s trying to introduce methylphenidate as the first pharmacological treatment for ADHD, describing the hostility he experienced from his colleagues. Professor Sir Sergeant concurred, describing the tremendous conflict that existed between clinicians at the time. However, there were many clinicians who were willing to get involved in research.
In 1986, the first meeting of what would later become EUNETHYDIS was held. Both men agreed that the European perspective was key to the later success of EUNETHYDIS, with their colleagues showing an ability to collaborate across centres years before this kind of approach became common in the US. Looking to the future, Professor Sir Sergeant highlighted the need for EUNETHYDIS to connect with the outside world to validate ADHD as a serious and debilitating illness. Finally, as the interview was brought to a close, the audience provided a standing ovation as the two men left the stage.
Professor Taylor: “It was hard introducing methylphenidate…I remember a colleague saying to me, ‘We don’t practise chemical warfare on our children.’”
Professor Taylor: “Joe had a very good vision right from the start…there is still a very strong junior component, which is what I think makes this meeting so extraordinary.”
Professor Coghill: “Across medicine, there are few groups this strong, this cohesive, with this history.”
- van Lieshout M, Luman M, Twisk JW, et al. A 6-year follow-up of a large European cohort of children with attention-deficit/hyperactivity disorder-combined subtype: outcomes in late adolescence and young adulthood. Eur Child Adolesc Psychiatry 2016; 25: 1007-1017.
- Buitelaar J. NeuroIMAGE – findings from a large prospective ADHD case-control study. Abstract from 4th EUNETHYDIS International Conference on ADHD. 2016; 17.
- Mowlem FD, Skirrow C, Reid P, et al. Validation of the Mind Excessively Wandering Scale and the Relationship of Mind Wandering to Impairment in Adult ADHD. J Atten Disord 2016 [Epub ahead of print].
- Inglis SK, Carucci S, Garas P, et al. Prospective observational study protocol to investigate long-term adverse effects of methylphenidate in children and adolescents with ADHD: the Attention Deficit Hyperactivity Disorder Drugs Use Chronic Effects (ADDUCE) study. BMJ Open 2016; 6(4):e010433.
- Banaschewski T, Zuddas A. Potential long-term effects of stimulant medication (results from the ADDUCE consortium). Abstract from 4th EUNETHYDIS International Conference on ADHD. 2016; 23.
- Ljung T, Chen Q, Lichtenstein P, et al. Common etiological factors of attention-deficit/hyperactivity disorder and suicidal behavior: a population-based study in Sweden. JAMA Psychiatry 2014; 71: 958-964.
- Cortese S, Moreira-Maia CR, St Fleur D, et al Association Between ADHD and Obesity: A Systematic Review and Meta-Analysis. Am J Psychiatry 2016; 173: 34-43.
- Nigg JT, Johnstone JM, Musser ED, et al. Attention-deficit/hyperactivity disorder (ADHD) and being overweight/obesity: New data and meta-analysis. Clin Psychol Rev 2016; 43: 67-79