Pharmacologic Management of ADHD in Children

Educational Objectives

The goal of this program is to improve the management of attention-deficit/hyperactivity disorder (ADHD) in children and adolescents. After hearing and assimilating this program, the clinician will be better able to:

1. Differentiate among the classes of medication used to treat ADHD.

2. Manage the potential adverse effects of ADHD medications.

3. Determine when dose adjustment or switching classes of medication is indicated for children with ADHD.

Summary

Attention-deficit/hyperactivity disorder (ADHD): prevalence has been increasing over last 2 decades; reported rates vary from 5% to 10%; Diagnostic and Statistical Manual of Mental Disorders, (Fifth Edition; DSM-5) made changes in diagnostic criteria (eg, age at onset, allowing coexistence with autism, minimum number of symptoms); diagnosis — clinical; rating scales have good negative predictive value, but neither positive result nor response to medication is diagnostic; must obtain thorough history (prenatal, birth, milestones); rating scales — include Conners Comprehensive Rating Scales, Child Behavior Checklist, and Swanson, Nolan, and Pelham-IV (SNAP-IV); Vanderbilt Assessment Scales most widely used

Comorbidities: almost two-thirds of children with ADHD have another behavioral or emotional disorder; behavior or conduct disorder most common; about one-third have comorbid anxiety

Nonmedical interventions: school-based — having child sit at front of classroom; changing physical environment; establishing “504 plan” or Individualized Educational Plan; behavioral therapy — includes parent-focused training, cognitive behavioral therapy, and applied behavioral analysis

Medication: efficacy — landmark Multimodal Treatment Study of Children with ADHD (MTA; 1999) demonstrated efficacy of stimulant medication for ADHD in children 7 to 9 yr of age; children were randomized to 4 groups (closely monitored and titrated medication management; behavioral therapy; combination of medication and behavioral therapy; and community-based treatment); all groups demonstrated improvement over 14 mo, but improvement greatest in medication group; for core symptoms, no significant benefit found using combination therapy over medication alone; behavioral therapy beneficial for comorbid features; 3 approved classes of medication — stimulants (methylphenidate, amphetamine; US Food and Drug Administration [FDA] has approved stimulants for use in children); norepinephrine reuptake inhibitors (atomoxetine); and α2-adrenergic receptor agonists (eg, clonidine, guanfacine)

Stimulant therapy: before prescribing, refer to cardiologist if child has condition that predisposes to sudden cardiac death, repaired tetralogy of Fallot, or abnormality of coronary arteries; if child healthy with no significant family history, neither electrocardiography nor referral needed; stimulants can worsen seizure disorders; tic disorder — meta-analysis found that 5% to 7% of children started on stimulants develop new tics or worsening of previous tic disorder; percentage not significantly different from those taking placebo or different class of medication; choice of initial therapy — both methylphenidate and amphetamines have short- and long-acting forms; consider short-acting forms for young children (4-5 yr of age), although they may lead to re-emergence of symptoms and require more frequent dosing; long-acting forms often chosen for convenience, but if starting new medication in long-acting form, family and teachers may encounter 12 hr of significant adverse effects

Starting stimulant therapy: use lowest effective dose; short-acting forms may require 2 to 3 doses during day, but effect should be rapidly visible; at initial visit, inform patient and family that adjustment of medication likely and close follow-up needed; dextroamphetamine mixed salts and d-methylphenidate (dexmethylphenidate) are twice as potent as some other medications, so start with lower doses (methylphenidate [Concerta] is not same potency as dexmethylphenidate [Focalin]); online tool aids conversion between and within classes of medications

Special considerations: Concerta — must swallow whole; duration probably longest, but onset likely slowest (may not take effect while child on school bus in morning); capsule not absorbable; Metadate (methylphenidate) — intermediate onset; less long acting; Ritalin LA (methylphenidate) — long acting; typically onset faster but duration shorter; Focalin — rapid onset; Adderall XR (amphetamine salts) and lisdexamfetamine (Vyvanse) — intermediate onset; if Adderall XR wears off by evening, increase morning dose; Adzenys (amphetamine) — oral dissolvable tablet; concern for abuse; Mydayis (amphetamine mixed salts) — sprinklable; approved only for teenagers; Daytrana (methylphenidate) — patch; useful if concerned about abuse; onset 2 hr; change patch site and observe for contact dermatitis

Stimulants in practice: if patient not adherent or having difficulty, change form (pill, liquid, patch, dissolvable); counsel parents on importance of giving medication every day (including weekend); in cases of adverse effects, minimal efficacy at high dose, or rating scales continuing to indicate persistent positive symptoms, consider switching within or between classes;

Children <6 yr of age: only dextroamphetamine approved by FDA; American Academy of Pediatrics and American Academy of Child and Adolescent Psychiatry agree that behavior therapy is first-line treatment for children 4 to 5 yr of age (should be continued for 10-14 wk); Preschool ADHD Treatment Study (PATS) found that young children with moderate to severe dysfunction benefit from methylphenidate at lower dose; young children more susceptible to adverse effects, such as emotional lability (start with short-acting form)

Adverse effects of stimulant therapy: appetite suppression; sleep disturbance; headache; abdominal pain; tics; conflicting data on possible growth suppression (during initial 1-3 yr of treatment); adult height typically not affected; consider changing medication if growth crosses 2 percentiles

Atomoxetine: useful for ADHD with comorbid anxiety; peak effect not achieved for 4 to 6 wk; may use as adjunct to stimulant therapy to boost effect (off label); black box warning for suicidality in teenagers and young adults

α-Adrenergic agonists: extended-release forms approved for ADHD (although little evidence for efficacy); anecdotal evidence suggests better effect on hyperactivity and impulsivity; potentially helpful for young children; rebound hypertension possible (must take every day); sedation most common side effect, which can be useful for children with trouble sleeping; clonidine and guanfacine have short-acting and long-acting forms (long-acting forms are Kapvay and Intuniv, respectively)

Troubleshooting: appetite suppression — take medication with or after meal; compensatory increase may occur as medication wears off; if severe, consider reducing dose or switching to different medication; try “drug holiday” on weekends and school breaks; cyproheptadine (Periactin) stimulates appetite (safe but has sedative effect); insomnia — counsel on sleep hygiene; melatonin appears effective for some children; clonidine at bedtime useful; trazodone may cause priapism; mirtazapine (Remeron) sometimes used; rebound irritability — add short-acting medication or switch to long-acting; lack of emotional affect — reduce dose

Duration of treatment: ≈33% of children outgrow ADHD, ≈33% require medication into adulthood, and ≈33% remain symptomatic but undiagnosed or not on medication; consider tapering dose if patient free of symptoms for >1 yr on medication, or if dose has not changed despite growth

Referral to psychiatry: considerations — diagnosis uncertain; response to stimulant medication poor (try ≥2 within each class); comorbidities challenging (eg, anxiety, depression, oppositional defiant disorder); medications not tolerated

Counseling families: medication effective for one family member may not be right for another child; monitor weight and blood pressure at least twice a year

Readings

Caye A et al: Treatment strategies for ADHD: an evidence-based guide to select optimal treatment. Mol Psychiatry 2019 Mar;24(3):390-408; Golmirzaei J et al: Psychopharmacology of attention-deficit/hyperactivity disorder: effects and side effects. Curr Pharm Des 2016;22(5):590-4; No authors listed: A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. Arch Gen Psychiatry 1999 Dec;56(12):1073-86; Partain PI et al: New stimulant formulations for pediatric attention-deficit/hyperactivity disorder: a case-based approach for the primary care provider. Curr Opin Pediatr 2019 Feb;31(1):166-74; Pliszka S; AACAP Work Group on Quality Issues: Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2007 Jul;46(7):894-921; Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management; Wolraich M et al: ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics 2011 Nov;128(5):1007-22; Vitiello B et al: Pharmacotherapy of the Preschool ADHD Treatment Study (PATS) children growing up. J Am Acad Child Adolesc Psychiatry 2015 Jul;54(7):550-6.

 

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose. In her lecture, Dr. Higginson presents information related to the off-label or investigational use of a therapy, product, or device. 

Acknowledgements

Dr. Higginson was recorded at The Jon B. Tingelstad Conference: Practical Pediatrics, presented by the Brody School of Medicine at East Carolina University, Department of Pediatrics and the Office of Continuing Medical Education, and by the UNC Eshelman School of Pharmacy, in association with the Eastern Area Health Education Center, and held May 9-10, 2019, in Greenville, NC. For information about upcoming CME conferences from the Brody School of Medicine at East Carolina University, please visit www.ecu.edu/cs-dhs/cme. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

PD662401

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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