Mental Health: Some Attention to Inattention

Column Author & Editor: Trenton Myers, MD | Child and Adolescent Psychiatry

Attention deficit hyperactivity disorder (ADHD) is a common pediatric condition in the U.S. Prevalence estimates in children and adolescents have nearly doubled since the early 1990s, to the current rate of about 10.5%. This article serves as a practical guide for ADHD diagnosis and treatment in the general practitioner’s office.

Diagnosis:
The Vanderbilt rating scale is the most frequently used tool for diagnosing ADHD. Most readers will already be familiar with this tool, but it is freely available online at the following link: https://upa.wustl.edu/wp-content/uploads/2015/09/ADHD_Assessment_NICHQ.pdf

It is important to note that, while rating scales are useful tools to support diagnostic suspicion, ADHD is a clinical diagnosis. Therefore, insufficient criteria on the Vanderbilt does NOT exclude a child from having ADHD. Although rating scales might appear to be objective, they are still very subjective (e.g., What is your definition of “occasionally,” “often,” or “very often”?). Most importantly for a diagnosis, there should be reason to believe that symptoms are negatively impacting a child’s social or academic functioning. ADHD symptoms should always be present in two or more settings, and evidence of symptoms should usually emerge prior to age 12. Ask parents if any elementary school teachers had concern for the child. If symptoms first present during the adolescent years, consider digital media use as a likely contributor. Anxiety and depression can also cause problems with attention but can also be comorbid or secondary to untreated ADHD. Pay attention to any psychological testing that has been completed for a child, as symptoms can be masked and tend to be harder to spot as a child ages. If a first-degree relative has ADHD, or if the child has had prenatal exposure to alcohol or tobacco, or a premature birth, your suspicion that ADHD is present should increase. Use your best clinical judgment in making the diagnosis. 

Treatment:

Pharmacotherapy is considered the most helpful intervention for children with ADHD, but behavioral therapies are helpful for ongoing oppositional/defiant behaviors and for comorbid anxiety/depression. Stimulant medications are generally recommended as first line, but in some situations non-stimulants may be recommended first.

What to know about stimulants:

• Advise parents at the beginning that there is much trial and error involved in finding the best medication and best dose for a child.
• There are two types of stimulants – methylphenidate derivatives and amphetamine derivatives. About 70%-85% of children respond to stimulant medications. About half of individuals respond equally to both types of stimulants. The other half respond preferentially to one type or the other. Therefore, a patient who responds poorly or with dose-limiting side effects to one type of stimulant may still benefit from a trial on the other type.
• An up-to-date list of all current ADHD medications on the market can be found at the following website: https://www.adhdmedicationguide.com/pdf/adhd_med_guide_122323.pdf
• Dosing is not based on size or weight of the child; it is based on response. About a third of children get adequate response to low doses of stimulants, about a third to medium doses, and about a third to higher doses. Titrate up to optimal effect while balancing with minimal/tolerable side effects.
• Stimulants work on days they are taken, not on days they are not. There is no “build-up” time required for stimulants.
• “Drug holidays” may be taken if there is significant appetite suppression or if it just works best for a family. However, growing evidence suggests that it may be optimal for stimulants to be taken every day due to the chronic and pervasive nature of ADHD.
• Long-acting formulations can be expected to provide a clinical effect for about six to eight hours after they are taken. Not all children are equal in their response, and this response time may vary by about two hours in both directions.
• Short-acting formulations last about three to four hours after they are taken. These may be useful as a booster to extend the effect in the afternoon when the long-acting formulation wears off. They may also be warranted in cases of excessive appetite suppression at lunch with extended-release forms, where a short-acting dose taken in the morning and after lunch may be a better fit.
• There is a lower incidence of abuse and diversion with long-acting formulations compared to short-acting formulations.
• Dosing of short-acting formulations should be about half of its long-acting counterpart to get the equivalent effect.
• You should use the same type of stimulant (amphetamine or methylphenidate) if a short-acting booster is needed.
• A baseline ECG should be obtained prior to starting a stimulant if there is a history of congenital cardiac abnormalities, syncope with exercise, family history of unexpected cardiac death under the age of 55, or family history of Wolff-Parkinson-White or Long-QT syndrome.

What to know about non-stimulants:

• There are currently four FDA-approved non-stimulants for ADHD. They include the alpha-2 agonists Intuniv (guanfacine ER) and Kapvay (clonidine ER), as well as the two norepinephrine transport inhibitors Strattera (atomoxetine) and Qelbree (viloxazine).
• Though they do not work as often as stimulants, non-stimulant medications may be an appropriate first-line choice in the following situations:
  • Families who have a strong preference against stimulant medications.
  • Children in which any appetite suppression would be extremely problematic.
  • Children with comorbid tic disorders, which may be exacerbated by stimulants (though this is not a contraindication to trying stimulants).
  • Families in which substance abuse or diversion is a significant concern.
  • Patients with comorbid anxiety and dyslexia who may benefit from an initial trial on atomoxetine.
• Non-stimulants may be a good augmentation agent for a stimulant if optimal effect is not obtained with a stimulant alone.
• All non-stimulants need to be swallowed whole, except for Qelbree, which can be opened and sprinkled on applesauce.
• Non-stimulants must be taken every day for at least two to four weeks to work effectively.
• Guanfacine has weight-based dosing between 0.05 and 0.12 mg/kg/day. Start at 1 mg per day and titrate up by 1 mg each week to the therapeutic dose range.
• Atomoxetine has weight-based dosing between 0.5 and 1.2 mg/kg/day. If a child is above 70 kg, then the 80 mg or 100 mg dose is preferred. To avoid excessive GI discomfort, start two pill-sizes lower than a child’s weight-based therapeutic dose for one week, then increase to the next dose for one week, then increase to the therapeutic dose and continue.
• Alpha-2 agonists may cause sedation, but the long-acting forms do not have this effect as much as the short-acting forms. Guanfacine causes less sedation than clonidine. Most of the side effects also improve with time.

If you have questions, feel free to call 1-800-GO-MERCY to speak with the on-call psychiatrist. We would love to help guide your treatment.

References:

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013. https://doi.org/10.1176/appi.books.9780890425596
2. Chan E. In: Tehrani N, ed. Attention deficit hyperactivity disorder in children and adolescents: epidemiology and pathogenesis. UpToDate; 2023. Accessed March 28, 2024. https://www.uptodate.com/contents/attention-deficit-hyperactivity-disorder-in-children-and-adolescents-clinical-features-and-diagnosis/
3. Boorady R. Stimulant medications for ADHD. Child Mind Institute. Accessed May 2, 2024. https://childmind.org/article/understanding-adhd-medications/
4. Brown KA, Samuel S, Patel DR. Pharmacologic management of attention deficit hyperactivity disorder in children and adolescents: a review for practitioners. Transl Pediatr. 2018;7(1):36-47. doi:21037/tp.2017.08.02
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6. 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;46(7):894-921. doi:10.1097/chi.0b013e318054e724
7. Stevens J R, Wilens TE, Stern TA. Using stimulants for attention-deficit/hyperactivity disorder: clinical approaches and challenges. Prim Care Companion CNS Disord. 2013;15(2):PCC.12f01472. doi:4088/PCC.12f01472
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