ADHD and AR: Attack AR first

Treating allergic rhinitis (AR) in children with attention-deficit/hyperactivity disorder (ADHD) appears to significantly improve not only AR, but also ADHD symptoms.

A previous study showed that children with untreated AR suffer significantly more ADHD symptoms than healthy controls.¹ To see if AR treatment could decrease these elevated ADHD symptoms, investigators enrolled 68 drug-naïve children with AR (aged 6 to 14 years) and evaluated their AR and ADHD symptoms before and after AR therapy. Using subjective and objective measurements, researchers showed for the first time that higher ADHD scores in children with AR improved with AR treatment, regardless of the form of AR treatment.²

"The main implication of our study is that increased ADHD symptom scores were noted in the children with AR, and these ADHD-like symptoms can be reduced by AR therapy. When community pediatricians face children with atopic diseases combined with inattention, hyperactivity, and impulsivity, do not jump to the presumptive diagnosis of ADHD and treat them with ADHD medication before trying AR treatment," says study coauthor Ming-Tao Yang, MD, in an interview. He is chief of the pediatric intensive care unit at Far Eastern Memorial Hospital in New Taipei City, Taiwan.

In the study, parents rated their children's AR symptoms using the 4-point Total Nasal Symptom Score (TNSS) before and after treatment. After a discussion with a physician, parents chose 1 of 4 AR treatment strategies for their child: oral antihistamines, topical corticosteroids, combined oral antihistamines and topical corticosteroids, or nonpharmacologic interventions. Investigators defined improvement as a TNSS reduction of at least 2 points at a follow-up visit 1 month after starting AR therapy.

As one might expect, mean TNSS scores fell, from 5.48 ±2.53 at baseline to 3.67 ±2.70 at follow-up (P<0.001). As participants' AR symptoms improved, so did several measures of their ADHD symptoms. At follow-up, mean scores for inattention (IA) and hyperactivity/impulsivity (HI) on both the Swanson, Nolan, and Pelham (SNAP) version IV questionnaire and the Diagnostic and Statistical Manual of Mental Disorders(DSM) diagnostic criteria as rated by parents declined significantly. Here, the most statistically significant declines involved parent-assigned mean HI scores on both the SNAP (from 9.73 ±5.96 at baseline to 7.62 ±5.21, P=0.001) and DSM scales (from 2.78 ±2.45 at baseline to 1.70 ±2.11, P<0.001).

To counteract a possible placebo effect on the parent-assigned scores, investigators measured children's performance on the Continuous Performance Test (CPT), a 14-minute computerized assessment of attention and impulsivity that records children's responses, using a keyboard, to specific stimuli. In this analysis, commission errors (such as hitting the wrong key) and detectability (of ADHD-like symptoms) declined significantly (P<0.001 for both). In addition, hit reaction time increased (P<0.05), indicating less impulsivity to response. After investigators controlled for confounding variables (age, multiple atopic diseases, and AR treatment), improved TNSS correlated positively with improved detectability and commission errors (P=0.001 and 0.011, respectively).

Despite the lack of a control group, the authors write, "No matter with nonpharmacologic or pharmacologic AR intervention, the finding that the ADHD tendency in some children with AR improved without ADHD medication was undoubted." At follow-up, parents gave children in the nonpharmacologic treatment group significantly better SNAP HI subscale scores; this group's CPT commission errors and detectability also improved (P<0.01). Because even nonpharmacologic treatments improved ADHD scores significantly and AR symptoms (albeit modestly), the authors write that in appropriate cases, "Nonpharmacologic intervention, eg, allergen avoidance, is worth a try."

In the oral and topical treatment groups, commission errors and detectability also decreased significantly (P<0.01). In the combination group, DSM HI subscale scores, as well as detectability, decreased significantly (P<0.05). However, pharmacologic treatments had a somewhat mixed impact. They provided better response rates for AR symptoms than nonpharmacologic treatments did overall, but AR drugs exerted a negative effect (-0.349, P=0.007) on improved HI scores posttreatment.

Multivariate linear regression analysis showed that significant predictors of improved ADHD scores after AR treatment included younger age, multiple atopic diseases, AR drugs, and AR subtypes. Among AR subtypes, children with persistent to moderate/severe AR showed the most significant improvement in their ADHD scores.

When community pediatricians treat AR in children with possible ADHD, says Yang, "Monitor the treatment response using the ADHD symptom scores, eg, SNAP-IV scale, just as in the treatment of children with typical ADHD." However, if a child's AR scores decline and ADHD symptoms increase while on AR treatment, he says, consider comorbid allergic rhinitis and ADHD. If such children meet diagnostic criteria for ADHD, "Adding ADHD medication is suggested."

REFERENCES

1. Yang MT, Lee WT, Liang JS, Lin YJ, Fu WM, Chen CC. Hyperactivity and impulsivity in children with untreated allergic rhinitis: corroborated by rating scale and continuous performance test. Pediatr Neonatol. 2014;55(3):168-174.

2. Yang MT, Chen CC, Lee WT, Liang JS, Fu WM, Yang YH. Attention-deficit/hyperactivity disorder-related symptoms improved with allergic rhinitis treatment in children. Am J Rhinol Allergy. 2016;30(3):209-214.