ADHD Diagnosis a Detective's Job

[Guest guest]

ADHD Diagnosis a Detective's Job

An Expert Interview With Dopheide, PharmD, BCPP

Jim Kling

April 12, 2011 — Editor's note: Attention deficit/hyperactivity disorder

(ADHD) affects about 3% to 7% of children in the United States. Stimulants are

an effective therapy, with a number needed to treat of 2, but parents often have

concerns about the short-term and long-term adverse effects of medical therapy.

A discussion of this issue was featured at the APhA 2011: American Pharmacists

Association Annual Meeting and Exposition, held March 25 to 28 in Seattle,

Washington.

To find out more about pharmacological management of ADHD, Medscape Medical News

interviewed Dopheide, PharmD, BCPP, an associate professor of clinical

pharmacy, psychiatry, and behavioral sciences at the University of Southern

California Schools of Pharmacy and Medicine in Los Angeles. Dr. Dopheide is a

board-certified psychiatric pharmacist and provides clinical services for adults

and children with psychiatric illness.

Medscape: Please talk about the importance of accurate diagnosis of ADHD.

Dr. Dopheide: You need to do a little detective work and figure out all the

possible causes of inattention, impulsivity, and hyperactivity.

I think you need a child psychiatrist to really tease out what's going on. Could

it be an anxiety disorder or a mood disorder? Sometimes a psychologist is needed

to see if a child has a learning disability. It's important to go beyond the

pediatrician to someone who can [offer] an extensive differential diagnosis. You

want to see how the symptoms are in multiple settings, such as at school and at

home. These are significant medications and you really want to be sure someone

has the condition before prescribing them.

Medscape: How do you address parents' concerns about medications?

Dr. Dopheide: A lot of times parents are hesitant. Many want nonpharmacological

treatments for their children. There are some available, such as keeping a

consistent schedule, instituting positive rewards for good behavior, and

breaking up homework into smaller, more manageable assignments. However, these

are oftentimes not effective unless the underlying brain problem is addressed.

There really are underlying brain changes that have been uncovered. There are

changes in dopamine receptor density in unmedicated patients with ADHD, compared

with controls. Other studies have found a delay in cortical thickening. These

children don't develop their executive functioning and decision-making

capabilities until later, and that predisposes them to inattention, impulsivity,

and hyperactivity.

Giving medication can help the individual participate in nonpharmacological and

behavioral therapy, but you have to start by finding the right medication for a

patient, given side effect sensitivity.

If one stimulant is ineffective, another category of stimulants might be

[effective]. Most people also prefer once-daily products, which is better than

giving them 3 times a day because the school nurse doesn't have to get involved,

and there's less chance for drug diversion.

I also emphasize some of the other treatment options. [Atomoxetine, a selective

norepinephrine reuptake inhibitor] doesn't tend to have the growth effect or

insomnia that is associated with stimulants.

Medscape: What do you say to parents who are concerned about the adverse effects

of medications?

Dr. Dopheide: There are both short-term and long-term effects of these

medications. Parents are often really worried about their child becoming a drug

addict or developing a problem with drugs if they are given a drug that has

abuse potential. But a large trial showed that ADHD itself is associated with a

larger rate of substance abuse and delinquency, and there's no evidence that

giving a stimulant makes them more likely to get into drug or alcohol abuse.

Clinicians and family members have to be more vigilant for abuse with ADHD

patients generally, because they may be self-medicating with an addictive drug.

If patients are actively abusing drugs, whether they are preteens, adolescents,

or adults, there are drugs that can be used to treat that, such as [bupropion].

I think it's really important to look at the positives and negatives, the risk

vs the benefit of drug therapy.

If I effectively treat ADHD, it can really help with a child's family life.

Quality-of-life studies show that when an individual is treated with

methylphenidate and clonidine, quality of life and family interactions are

better than in placebo groups. Another study of academic achievement in

elementary school kids shows that treatment can improve math and reading scores.

Medscape: What about concerns related to growth effects?

Dr. Dopheide: There is a real risk of decreased height associated with ongoing

stimulant use. It's not a very large effect — you're talking about 1 cm per

year over 3 years — but some may view it as significant and it needs to be

monitored. It's possible that if they go off the medicine for a " holiday " period

they might have some growth rebound, but it's really unknown whether, for

example, taking them off medication on weekends is enough to help with growth

problems.

The downside is that people can have symptom reemergence that could disrupt

their life. Other strategies include lowering the dose, but that can compromise

the therapeutic efficacy. If they're going to try a drug holiday, they should do

it when a child is not in school and carefully weigh the risks vs benefits, and

then be sure to put them back on the medication before they start school again.

Cardiovascular side effects are another issue. There is a warning of sudden

unexplained death with use of ADHD [stimulants], which is really scary [to

parents in particular]. But [that warning] needs to be put into context. When

you look at the problems that children, adolescence, and even adults have run

into with cardiovascular side effects, in most cases there was an underlying

cardiovascular abnormality. It is also possible that people taking multiple

medications could be at increased risk for cardiovascular side effects, so

monitoring is needed. Anyone taking medications that can increase heart rate

need [electrocardiogram] and cardiac evaluations to see how the medicines are

affecting them.

There is also a report that general anesthesia can be more dangerous for people

taking ADHD and stimulant medications. The theory is that the stimulant may

impair the sympathetic recovery that you need to recover from anesthesia. I

think it's a good idea to discuss this with the physician or anesthesiologist if

a child is on these medications, and perhaps even taper them off the medication

before having any surgery that involves general anesthesia.

Medscape: How do you encourage parents to have a positive outlook?

Dr. Dopheide: It's good to think of ADHD people as having different brains. We

need to give them the tools to improve their attention and function so that we

can help them succeed in life, do well in school, and have healthier

relationships. ADHD can change over time, and some people may not need treatment

into adolescence and adulthood, but some will. Treatment should be reassessed

annually to see if there needs to be a dose adjustment.

We know the consequences of untreated ADHD: poor self esteem, not doing as well

in school, problems with social relationships. Parents need to be told that

medication can help their child's growth and development. One option for further

information is a Web site called CHADD (which stands for Children and Adults

with Attention Deficit/Hyperactivity Disorder).

Dr. Dopheide has disclosed no relevant financial relationships.