Long-term follow-up of patients treated with the edgewise crowned Herbst appliance in the mixed dentition

Objectives. Research has indicated that the bite jumping technique employed by the crowned Herbst appliance can be effective in correcting Class II skeletal abnormalities by promoting growth of the mandible and remodeling of the glenoid fossa. This research investigated the skeletal and dental alterations of Class II patients treated at an early age with the edgewise crowned Herbst appliance and evaluated the long term stability of those effects. Methods. Cephalometric analysis was performed for a treatment group consisting of 22 radiographs taken before phase I treatment (T1), immediately after Herbst removal during phase I treatment (T2), at the completion of phase I treatment (T3), prior to beginning of phase II orthodontic treatment (T4), and immediately following phase II orthodontic treatment (T5). Measurements were compared to a matched control sample of untreated Class II patients from the Bolton-Brush study. The difference in each variable between the treatment and control groups across the five time periods was analyzed for pooled subjects, and separately for male and female subjects. The differences between certain time points were analyzed to investigate treatment changes and their stability over time. For all time periods, the change in the values of the variables for pooled subjects, male subjects, and female subjects in the treatment group were compared to the change in the values of the variables for pooled subjects, male subjects, and female subjects in the control group, respectively. In total, 37 variables were evaluated for each group including sagittal variables, vertical variables, angular variables, and condyle/glenoid fossa variables. In addition, an evaluation of the overjet correction and molar relationship correction for the treatment groups and an evaluation of the net overjet correction and net molar relationship correction for the treatment vs. control groups at each time period for pooled subjects were performed. Results. Treatment of Class II patients treated with the crowned Herbst appliance in the early mixed dentition resulted in the following changes relative to normal growth: The forward movement of the maxillary base (OLp-A pt) was initially restrained after treatment (T2-T1) and gradually became more restrained in the short-term (T3-T1) and long-term (T4-T1) post-treatment periods. An even greater restraint was seen after phase II orthodontics (T5-T1). The mandibular base (OLp-Pg) was initially moved forward after treatment (T2-T1), however, a gradual relapse was seen in the short-term (T3-T1) and long-term (T4-T1) post-treatment periods. Additional relapse in a posterior direction was seen after phase II orthodontics (T5-T1). The maxillary molars (Ms-OLp) were initially distalized (T2-T1), relapsed slightly in the short-term post-retention period (T3-T1), and became distalized again in the long-term post-treatment period (T4-T1). The maxillary molars were mesialized during phase II orthodontic treatment (T5-T4) and most of the overall posterior molar movement was eliminated after this period (T5-T1). The mandibular molars (Mi-OLp) were initially mesialized after treatment (T2-T1), however gradual relapse occurred during the short-term post-treatment period (T3-T1) until they returned to their pre-treatment position after the long-term post-treatment period (T4-T1). They were mesialized again after phase II orthodontic treatment (T5-T1). The maxillary incisors (Is-OLp) moved backward and retroclined after treatment (T2-T1), then relapsed slightly during the short-term (T3-T1) and long-term (T4-T1) post-treatment period. A net posterior movement was maintained through the long-term post-treatment period (T4-T1). This posterior position of the maxillary incisor remained stable through phase II treatment (T5-T1). The mandibular incisors (Ii-OLp) moved forward and proclined after treatment (T2-T1), then relapsed to their pre-treatment position after the short-term post-treatment period (T3-T1). Forward movement and proclination occurred during the long-term retention period (T4-T3), giving a net forward movement and proclination after this period (T4-T1). The mandibular incisors returned to their pre-treatment position after phase II orthodontic treatment (T5-T1). A net overjet correction of 7.0 mm occurred after treatment (T2-T1), then relapsed in the short-term post-treatment period (T3-T1) until a relatively stable net overjet correction between 2.5-3.0mm was maintained over the long-term (T4-T1). The overjet correction remained stable through phase II treatment (T5-T1). A molar relationship correction of 6.6 mm occurred after treatment (T2-T1), then relapsed in the short-term post-treatment period (T3-T1) until a relatively stable net molar correction between 2.2-3.3mm was maintained over the long-term (T4-T1). The molar correction remained stable through phase II treatment (T5-T1). Relocation of the glenoid fossa occurred in an anterior and superior direction after treatment (T2-T1) and this relative change in position was stable over the long term (T4-T1). Restriction of the downward and backward movement of the fossa was observed and might additionally contribute to Class II correction. Conclusions. The results of this study suggest that early treatment with the edgewise crowned Herbst appliance can achieve overjet correction and molar relationship correction that remains stable over the long-term. However, the skeletal and dental contributions to this overjet and molar correction shift over time with decreasing skeletal contribution and increasing dental compensation. During phase II orthodontic treatment, an increased skeletal contribution to overjet and molar relationship correction occurs

A Double-Blind, Placebo-Controlled Withdrawal Trial of Dexmethylphenidate Hydrochloride in Children with Attention Deficit Hyperactivity Disorder

Objectives: d,l-threo-methylphenidate HCl (d,l-MPH) is the most common treatment of attention deficit hyperactivity disorder (ADHD). A previous report showed placebo-controlled efficacy for the purified disomer (dexmethylphenidate hydrochloride, d-MPH, Focalin™) with a 2:1 potency compared to dl, and suggested a 6-hour duration of action. This study complements that report by studying the effect of placebo-controlled discontinuation and retesting the duration of action. Methods: A 6-week, open-label titration of d-MPH (2.5–10 mg twice-a-day) was followed by a doubleblind, placebo-controlled, 2-week withdrawal study of responders. Results: In the open titration, 82% of the 89 enrolled patients achieved a Clinical Global Impression— Improvement (CGI-I) rating of much or very much improved. Only 5 patients discontinued for adverse events. Seventy-five patients continued into the placebo-controlled discontinuation. For the randomly assigned d-MPH (n = 35) and placebo (n = 40) groups, mean ages, respectively, were 10.1 ± 2.9 and 9.9 ± 2.7 years, 86% and 78% were male, and 70.6% and 80.0% took the ceiling dose of 10 mg twice-daily, respectively. Each group had 80% combined-type ADHD and 20% inattentive type. By the end of the 2- week, placebo-masked withdrawal, significantly more placebo patients (24 of 39) than d-MPH continuers (6 of 35) relapsed (61.5% versus 17.1%, p = 0.001). Compared to d-MPH continuers, placebo patients deteriorated significantly more in the 2-week period on teacher ratings of the 18 ADHD symptoms rated 0– 3 (p = 0.028), the 3 p.m. and 6 p.m. parent ADHD symptom ratings (p = 0.0026 and p = 0.0381, respectively), and clinic (2–3 p.m.) and home (6 p.m.) Math Tests (p = 0.024 and p < 0.0001, respectively). The 6 p.m. scores replicated the significant effect at 6 hours reported in the previous study. Conclusions: d-MPH is safe, tolerable, and effective, with a 6-hour duration of effect suggested by the significant difference from placebo at 6 hours on a double-blind discontinuation

Child and Parent Predictors of Perceptions of Parent–Child Relationship Quality

Objective/Method: Predictors of perceptions of parent–child relationship quality were examined for 175 children with ADHD, 119 comparison children, and parents of these children, drawn from the follow-up phase of the Multimodal Treatment Study of Children with ADHD. Results/Conclusion: Children with ADHD perceived their mothers and fathers as more power assertive than comparison children. Children higher on depressive symptomatology also perceived their mothers and fathers as less warm and more power assertive. Mothers perceived themselves as more power assertive and fathers perceived themselves as less warm if they were higher on depressive symptomatology themselves or had children with ADHD or higher levels of depressive symptomatology. Several interactions indicated that the association between child factors and parental perceptions of warmth and power assertion often depended on parental depressive symptomatology. The findings resolve a previous contradiction in the literature regarding the relationship between child depressive symptoms and parental perceptions of parent–child relationship quality

Acetyl-L-Carnitine in Attention-Deficit/Hyperactivity Disorder: A Multi-Site, Placebo-Controlled Pilot Trial

Objective: To determine whether acetyl-L-carnitine (ALC), a metabolite necessary for energy metabolism and essential fatty acid anabolism, might help attention-deficit/hyperactivity disorder (ADHD). Trials in Down’s syndrome, migraine, and Alzheimer’s disease showed benefit for attention. A preliminary trial in ADHD using L-carnitine reported significant benefit. Method: A multi-site 16-week pilot study randomized 112 children (83 boys, 29 girls) age 5-12 with systematically diagnosed ADHD to placebo or ALC in weight-based doses from 500 to 1500 mg b.i.d. The 2001 revisions of the Conners’ parent and teacher scales (including DSM-IV ADHD symptoms) were administered at baseline, 8, 12, and 16 weeks. Analyses were ANOVA of change from baseline to 16 weeks with treatment, center, and treatment-by-center interaction as independent variables. Results: The primary intent-to-treat analysis, of 9 DSM-IV teacher-rated inattentive symptoms, was not significant. However, secondary analyses were interesting. There was significant (p = 0.02) moderation by subtype: superiority of ALC over placebo in the inattentive type, with an opposite tendency in combined type. There was also a geographic effect (p = 0.047). Side effects were negligible; electrocardiograms, lab work, and physical exam unremarkable. Conclusion: ALC appears safe, but with no effect on the overall ADHD population (especially combined type). It deserves further exploration for possible benefit specifically in the inattentive type

Parent Agreement on Ratings of Children's Attention Deficit/Hyperactivity Disorder and Broadband Externalizing Behaviors

Mothers and fathers often disagree in their ratings of child behavior, as evidenced clinically and as supported by a substantial literature examining parental agreement on broadband rating scales. The present study examined mother-father agreement on Diagnostic and Statistical Manual-based symptom-specific ratings of Attention-Deficit/Hyperactivity Disorder (ADHD), as compared to agreement on broadband ratings of externalizing behavior. Based on mother and father ratings of 324 children who participated in the Multimodal Treatment Study of Children with ADHD (MTA), parental agreement was computed and patterns of disagreement examined. Mother-father ratings were significantly correlated; however, a clear pattern of higher ratings by mothers was present. Agreement on attention-deficit/hyperactivity disorder symptom-specific ratings was significantly lower than that for broadband externalizing behaviors and oppositional defiant disorder symptoms. Of several moderator variables tested, parental stress was the only one that predicted the discrepancy in ratings. Disagreement between parents is clinically significant and may pose complications to the diagnostic process

Evidence, Interpretation, and Qualification From Multiple Reports of Long- Term Outcomes in the Multimodal Treatment Study of Children With ADHD (MTA) Part II: Supporting Details

Objective: To review and provide details about the primary and secondary findings from the Multimodal Treatment study of ADHD (MTA) published during the past decade as three sets of articles. Method: In the second of a two part article, we provide additional background and detail required by the complexity of the MTA to address confusion and controversy about the findings outlined in part I (the Executive Summary). Results: We present details about the gold standard used to produce scientific evidence, the randomized clinical trial (RCT), which we applied to evaluate the long-term effects of two well-established unimodal treatments, Medication Management (MedMGT) and behavior therapy (Beh), the multimodal combination (Comb), and treatment “as usual” in the community (CC). For each of the first three assessment points defined by RCT methods and included in intent-to-treat analyses, we discuss our definition of evidence from the MTA, interpretation of the serial presentations of findings at each assessment point with a different definition of long-term varying from weeks to years, and qualification of the interim conclusions about long-term effects of treatments for ADHD based on many exploratory analyses described in additional published articles. Conclusions: Using a question and answer format, we discuss the possible clinical relevance of the MTA and present some practical suggestions based on current knowledge and uncertainties facing families, clinicians, and investigators regarding the long-term use of stimulant medication and behavioral therapy in the treatment of children with ADHD. (J. of Att. Dis. 2008; 12(1) 15-43

Peer-Assessed Outcomes in the Multimodal Treatment Study of Children With Attention Deficit Hyperactivity Disorder

Peer-assessed outcomes were examined at the end of treatment (14 months after study entry) for 285 children (226 boys, 59 girls) with attention deficit hyperactivity disorder (ADHD) who were rated by their classmates (2,232 classmates total) using peer sociometric procedures. All children with ADHD were participants in the Multimodal Treatment Study of Children with ADHD (MTA). Treatment groups were compared using the orthogonal treatment contrasts that accounted for the largest amount of variance in prior MTA outcome analyses: Medication Management + Combined Treatment versus Behavior Therapy + Community Care; Medication Management versus Combined Treatment; Behavior Therapy versus Community Care. There was little evidence of superiority of any of the treatments for the peer-assessed outcomes studied, although the limited evidence that emerged favored treatments involving medication management. Post hoc analyses were used to examine whether any of the four treatment groups yielded normalized peer relationships relative to randomly selected- classmates. Results indicated that children from all groups remained significantly impaired in their peer relationships

Robotic Application of Particle Swarm Optimization Algorithm

Swarm algorithms are generally used to find the optimal solution to a given problem using multiple particles that collect data. This swarm algorithm is executed by multiple robots that search for the hottest location on an arena by communicating and working together. These robots use their current direction, the location of their hottest recorded temperature, the location of the swarm’s hottest recorded temperature, and a random vector to determine where to search next. By varying these weighted components, this application seeks an optimal algorithm for locating the hottest spot on the arena in an efficient manner. This kind of work has thus far been limited to study in the realm of computer science. Our work is some of the first to expand this research to actual robotics. We expect to learn how this algorithm must be modified to be practical in real life implementations. A few complications that we are particularly interested in include the implication of real space as opposed to the points or pixels to which theoretical algorithms are limited. The sensitivity of the robots to hot spots, both those found by the swarm and those found by the individual robots, will determine the efficiency of the algorithm, and by varying these sensitivities we can find an optimal algorithm. Lastly, we hope to optimize the algorithm by stratifying the temperatures of hot spots and distributing jobs among the robots such that each robot is exploring a different strata of temperature