Practical approaches for ADHD treatment

December 2005

Attention-deficit/hyperactivity disorder (ADHD) is a common childhood disorder that can persist into adulthood and cause significant impairment and morbidity.

However, with careful assessment and optimized treatment strategies, improvements can be made in functioning and quality of life, said Christopher J. Kratochvil, MD, at the AAP National Conference and Exhibition, held in Washington.

“Pharmacotherapy is an important part of the treatment of ADHD, with adjunctive behavioral therapy adding additional benefits for many of the children with ADHD,” he told Infectious Diseases in Children. “Treating each child individually, titrating the medication to the optimal dose and monitoring the onset and offset of action of the medication can help to provide the child with optimal treatment.”

The CDC estimated that about 4.4 million (7.8%) U.S. children aged 4 to 17 have a history of ADHD. Up to 80% continue to have impairments into adolescence and up to 60% in adulthood.

Monitoring and identifying ADHD

Proper treatment tailored toward the patient’s needs can reduce the sequelae of ADHD persisting through adolescence into adulthood, explained Kratochvil, associate professor in the department of psychiatry at the University of Nebraska Medical Center in Omaha.

ADHD management require an organized and methodical approach. Behavioral interventions, school interventions, community support and medication management are important parts of a treatment plan, according to Kratochvil. Teaching the parents and the child about ADHD, what it is, what the long-term outcome is and what to expect, is important.

“Parent training can be invaluable,” he said. “Combination therapy is probably the gold standard. For one thing those kids may get by with lower doses of medication. Another thing, there are benefits beyond those core symptoms like peer interaction, parent-child relations, academic achievement and social skills.”

Findings from the Multimodal Treatment Study of Children with ADHD, or the MTA study, showed that physicians are not optimizing therapy as well as possible, according to Kratochvil. Children with a learning disability, obsessive-compulsive disorder, general anxiety disorder, depression or even mental retardation may exhibit similar symptoms; therefore, it is important to follow the DSM-IV criteria when making an ADHD diagnosis to help distinguish between different disorders and a child just being a child, he said.

“The reason is, if you just take a kid who is hyper and not focusing, you don’t know that it’s necessarily ADHD,” he said. “You really need to go through those DSM-IV criteria and confirm diagnosis.”

Once diagnosed, Kratochvil recommended documenting baseline symptom severity to monitor the medicine’s effectiveness, optimal dosage and adverse events and assess the patient for comorbidity. The AAP’s ADHD Tool Kit is helpful in diagnosis, treatment, ongoing clinical management and screening questions to look for comorbidities, such as anxiety, depressive symptoms, oppositionality and defiance in children and adolescents with ADHD.

Another widely used tool is the ADHD-IV Rating Scale, which provides norms for children based on age and gender. This tool helps identify underlying issues. It is also important to monitor drug compliance and track any weight, height, blood pressure and pulse changes.

Newer delivery options

One of the bigger advancements in ADHD treatment is creating ways to provide multiple doses in a single pill with immediate-release and extended-release options. For example, among methylphenidates, Metadate CD (Celltech) offers 30% immediate release and 70% release three hours later. Ritalin LA (Novartis) and Focalin XR (Novartis) offer 50% immediate release and the rest about four hours later. Among amphetamines, Adderall XR (Shire) works in the same way, half immediately and half four hours later. Concerta (McNeil) uses a technology based upon a sustained-release capsule with an overcoat of immediate release methylphenidate.

Kratochvil suggested that stimulants seem to be fairly equal in responsiveness. Atomoxetine (Strattera, Lilly) is a newer treatment and is dosed according to body weight. It is administered at 0.5 mg/kg a day and is titrated to target doses to improve tolerability. Initial therapeutic effects with this regimen may not be evident for about a week or two, with full effects often taking several weeks. It is important to communicate this information with family members so they know what to expect.

When using medication, a clinician must consider how long medication works, as well as its optimal dose.

With every treatment come possibilities for adverse events. Adverse events associated with ADHD treatments include decreased appetite and potentially growth, stomachaches and nausea. To reduce these adverse events, administer medications during or after meals and provide ample snacks throughout the day. If the weight loss continues, he recommended using PediaSure or other calorie enhancing strategies to ensure that the child is receiving enough calories. The more common adverse events associated with atomoxetine use are dyspepsia, nausea, vomiting, fatigue, decreased appetites and mood swings. Atomoxetine can be an irritant to the stomach, so administer it with food. If upset stomach persists, divide the dose.

“Educating children and their families about potential side effects and how to address them can have a significant impact on compliance and tolerability,” he said.

The most common comorbid diagnoses in children with ADHD are oppositional defiant behavior, anxiety, mood conduct and learning disorders.

When symptoms of ADHD progress beyond childhood, adolescents often suffer from an inner sense of restlessness, disorganized schoolwork, poor follow through, risky behavior, poor self-esteem, poor peer relationships and difficulty with authority. If ADHD extends into adulthood, it increases the risk of depression, anxiety and substance abuse.

“Comorbidites are the rule rather than the exception,” Kratochvil said. “They can impact the level of impairment on the child and may require additional treatments to address target symptoms.”

Pharmacotherapy is one of the most effective treatments for children with ADHD, according to the MTA study; however, there are limited clinical studies on treatment among the 3- to 5-year-old age group. Epidemiological studies show that about 2% of preschoolers have ADHD, and DSM-IV requires onset of symptoms by 7 years old. The FDA approved methylphenidate for children aged 6 and older, and it is the only pharmacotherapy with controlled study data available in children younger than 6.

“Preschool-aged ADHD is a real clinical issue. If you think of ADHD as a neurodevelopment disorder, it is certainly not surprising that it’s going to present at a young age,” he said.

Current and future studies

Kratochvil highlighted recent findings from the Preschool ADHD Treatment Study, a double-blind, placebo-controlled, multicity trial of methylphenidate in young children that showed methylphenidate to be beneficial among the children, but decreased dosage may be indicated. This study is under review for publication.

“As data start coming out, clinicians may be more confident in treating preschoolers; but again, be very cautious,” he said. “This is a population we don’t know a whole lot about. They’re undeveloped mentally and developing rapidly. If you do the risk-to-benefit analysis, this is a population that may well benefit with treatment, but warrant a thorough diagnostic evaluation and close follow-up.”

Two new pharmacotherapies are in the pipeline. One is a methylphendate patch for children. Another is modafinil (Provigil, Cephalon), which is under FDA review. Prior studies have shown that this drug increases alertness and task performance with three recent double-blind studies demonstrating greater improvement in ADHD symptoms than placebo.

“I think it’s very promising that we’re continuing to see new treatments and new delivery methods evolving, with a hope of providing additional treatment options for our patients with ADHD,” he said.

Dr. Kratochvil is a paid consultant for Eli Lilly and Shire.

For more information:

• Kratochvil C. Medications for ADHD: practical approaches to optimizing treatment. Session #S277. Presented at the AAP National Conference and Exhibition. Oct. 8-11, 2005. Washington.
• CDC. Mental health in the United States: prevalence of diagnosis and medication treatment for attention-deficit/hyperactivity disorder – United States, 2003. MMWR. 2005;54:842-847.
• The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 1999:56;1073-1086.