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ADHD Part 2

Todd Flosi, MD, Stephanie D'Augustine, MD, and Rob Orman, MD
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Discuss diagnostic criteria for ADHD; Review therapeutic options for ADHD including changes to school environment, medications, omega 3, diet modifications.

Treatment Options for ADHD

How do you begin treatment?

  • The main treatment most physicians use for school aged children is stimulant medication. These meds tend to make the greatest difference. 
  • Review the components of the child’s general wellness before discussing medications. She makes sure the child is:
    • Eating a varied diet with an adequate breakfast before school.
    • Getting an appropriate amount of sleep at night.
    • Getting an adequate amount of outside time and exercise. 
    • Discuss what is happening in the school setting and brainstorm ways to improve the child’s experience.
    • Repeated instructions for homework assignments.
    • Extra time for test taking.
    • Preferential seating near the point of instruction.
    • Ear plugs for children who get distracted by the other kids around them.
    • Help for any learning differences that accompany the ADHD (504 plan or IEP plan). 

What is your opinion about Omega-3 supplementation for ADHD?

  • There is ongoing research on the use of Omega-3s, especially in the area of autism. There is evidence that fish oil supplementation may help ADHD symptoms in some kids. However, there are currently no large trials and not enough evidence to support Omega-3 as the primary treatment for ADHD.
  • Dr. D’Augustine does recommend supplements for many of her patients with ADHD. She first reviews ways to get adequate amounts in the child’s regular diet.
  • One problem is that the effective dose of Omega-3 is unknown. The general thought is that Omega-3 supplementation is unlikely to be harmful, so there is little downside to giving it a try. 
  • Dietary sources of Omega-3s:
    • Salmon, olives, flax, chia seeds.
    • Halibut, trout, oysters.
    • Fortified eggs.

 What is your go-to medication when starting pharmaceutical therapy for ADHD?

  • Most practitioners have their own favorites. 
  • Start with a stimulant medication. Stimulants  are backed by many years of research.
    Two main classes of stimulant medications: methylphenidate and amphetamine.  
  • Slightly less irritability with methylphenidates in her experience, although this is not backed in the general research. 
  • Some studies suggest that the amphetamine family may be more effective in some kids.
  • Stimulant medications can cause insomnia. 
  • If the methylphenidate is not effective or there are too many side effects, she will switch to an amphetamine. 
  • An exception:
    • Children who cannot swallow pills or who do not tolerate pouring the granules of medication onto a food source. Vyvance is a medication in the amphetamine family which is a powder that can be mixed with water and drunk by the child. 
  • Medication choice can depend on what duration of action you want the medication to have. Is short-acting (4 hours) sufficient or does the child require intermediate or longer duration? How long do you need to have the medication effect?
  • A preschooler who is only in school for four hours a day and has no homework can start on a short-acting medication which will cover the time the child is at school. If a child is severely impaired with hyperactivity or impulsivity to the point that it affects life outside of school, then extend the dosing from a four hour medication to a 12 hour medication. 
  • Teenagers and college students may benefit from even longer duration of effect. The stimulant medications can cause insomnia, so a non-stimulant such as Atomoxetine (Strattera) can be started in this population as it is effective for 24 hours. 

Does tolerance to medication develop thus requiring continual increase in dosage?

  • Most kids do not develop a tolerance, but some do. 
  • When kids enter puberty, ADHD can develop new and different manifestations. This may require adjustment in the medication regimen. 
  • When medication is first started, the family often sees a dramatic improvement very quickly. After a while, the dramatic improvement is not as obvious. This may indicate that some amount of tolerance is developing, or it may indicate that there is a new level of expectation for the child as they have had some success with attention and impulse control.
  • Start stimulant medications at the lowest dose possible to allow for titration.

Do certain medications work better for certain ADHD symptoms? Are some medications bad for certain symptoms?

  • In most cases, starting with any of the stimulant medications is fine. Specific medication choice is guided more by how long the child needs the medication effect to last, how the medication is tolerated in terms of side effects, and whether or not the child can swallow a pill. 
  • Within the stimulant medication family, there are not certain drugs that are preferable for a certain profile of ADHD symptoms. 
  • In terms of deciding between the methylphenidate and amphetamine families, consider co-morbidities, age and if the patient would be a candidate for a non-stimulant medication. 
  • Some children have baseline aggressive behavior or irritability in association with their ADHD. In these children, it may be better to begin drug therapy with an alpha-agonist, as opposed to a stimulant medication. 

Do you ever have a patient on two different medications?

  • Yes. The main situation is if a stimulant medication is started with great benefit to ADHD symptoms, but the child has a side effect of insomnia. In this case, an alpha-agonist can be added in the late afternoon or evening to help with the insomnia.
  • Another situation is if the stimulant cannot be titrated up to a level that improves all of the ADHD symptoms. An alpha-agonist can be added in the morning and evening. A  long-acting alpha-agonist (Intuniv) is also an option. 

Do you ever recommend that medications be taken only as needed? For example, on school days but not on the weekend; or discontinued during the summer.

  • Consider for children with the primarily inattentive ADHD in whom most of their impairment occurs in the school setting. If they do not experience  impairment when not doing academic work or in the school setting,Dr. D’Augustine recommends  stopping the medication during the summer. 
  • For many kids, impairment extends beyond just the school setting, so they should remain on medication during the weekends and summer. However, dosage can be decreased during the summer and weekends if tolerated by the child.

Is ADHD a lifetime diagnosis or is it something that can be outgrown?

  • The presentation of ADHD typically changes over time. 
  • For many kids with ADHD, there is more hyperactivity and impulsivity when they are younger. As they grow older these aspects can improve while the attention deficits can remain. 
  • Often, when people with ADHD go to college or find a career, they start to do things that are more interesting to them and therefore it is easier to maintain attention. This can allow some to stop medications when they enter adulthood. 
  • It’s not a matter of it being a lifetime diagnosis, but more a matter of how impairing it is and whether an individual chooses to continue the medication treatment into adulthood.

Are there gender differences in the presentation, diagnosis and/or treatment of ADHD? 

  • Yes: girls tend to present later than boys and with more inattentiveness than hyperactivity.  
  • Many girls will present as pre-teens or teenagers; often with mood difficulties or self esteem issues. This may be appear to be a normal part of growing up, but with a deeper history you may find that they have struggled with inattention and/or executive functioning (organizing, planning) for a long time. They may complete their homework and get good grades but it takes them twice as long as other kids, which can affect their self esteem.
  • Girls may be harder to diagnose at an earlier age. The approach to treatment for girls and boys is the same. 
  • It can be harder to monitor the effect of the treatment in pre-teen and teenage girls. Feedback from parents and teachers may not be as readily available because the girl is not disruptive; she is having difficulty focusing and staying on task, which may not be noticeable. In these patients the effect of treatment is not as obvious as when treating a hyperactive 8 year old. 

How do you approach parents who either strongly believe that their child needs treatment despite your doubts, or who strongly believe that their child does not need treatment despite evidence to the contrary? 

  • Respect the family’s preference to not use medication and then work with them through non-pharmacological treatment options. Closely monitor the child’s well-being as well as understand the potential negatives of choosing not to treat with medications. 
  • Start with well-being interventions (nutrition, sleep, exercise).
  • Be sure that the school is also involved in the treatment direction 
  • Provide parent training on effective communication with their child, how to help their child through homework, etc. 
  • Identify the most impairing behaviors for that specific child and then follow-up closely. 
  • Utilize a daily progress report from the child’s teacher as a reminder of how the child’s behavior and learning are in school. These notes can then be compared with the parents’ after several months to see if progress is being made.
  • Discuss with the parents that if progress is not being made, and if there is evidence of mood difficulties, increasing anxiety, school refusal or somatic symptoms, then medication should be re-considered. 
  • For families who are pushing for medication treatment when she doesn’t think that it is necessary, recommend non-pharmacologic interventions in conjunction with close monitoring of the child to see if progress can be made without medication first. 

Some studies suggest that children with ADHD who are treated and then reach adulthood have less likelihood to be smokers or use illicit drugs. Do you talk about those things with the family?

  • Yes. Some parents are concerned that the use of stimulant medications might cause the child to become addicted or have abuse problems later in life. However, most evidence suggests the opposite , at least through the teenage years and possibly into adulthood. Families can find this reassuring.

Final Discussion

  • There is controversy surrounding ADHD and its treatment. 
  • Many feel that is being over-diagnosed and over-medicated. While others believe that current treatments are life-changing. 
  • A 2013 New York Times article explored the controversy an multiple forces pulling in different directions in the ADHD conversation. http://www.nytimes.com/2013/12/15/health/the-selling-of-attention-deficit-disorder.html?pagewanted=all&_r=0
  • There has been heavy advertising by pharmaceutical companies directed at physicians and parents promoting stimulation medication for ADHD. 
  • “The FDA has cited every major ADHD drug for false and misleading advertising since 2000. And some multiple times.”
  • A recent report has linked methylphenidate (the active ingredient in Ritalin) and the Daytrana patch with priapism. The Daytrana patch has been linked to tardive dyskinesia. 
  • The AAP and the AACP have guidelines on diagnosing and managing ADHD which are excellent resources. 
  • A 2014 New England Journal of Medicine Clinical Practice article on ADHD is also a good resource. http://www.nejm.org/doi/full/10.1056/NEJMcp1307215

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These Crazy Kids Are All Elbows and Rashes Full episode audio for MD edition 203:42 min - 96 MB - M4AHippo Peds RAP February 2015 Summary 498 KB - PDF