How effective are ADHD medications in adults with Autism Spectrum Disorder (ASD)?

Stephen V. Faraone, PhD on December 26, 2019

Autism spectrum disorder (ASD) is frequently comorbid with ADHD. Among adults with ADHD, as many as half are reported to also have ASD.

A Dutch team set out to answer two questions:

  1. Do adults with ADHD and comorbid ASD experience less effectiveness of pharmacological treatment for ADHD than adults with only ADHD?
  2. Do adults with ADHD and comorbid ASD experience different or more severe side effects of pharmacological treatment for ADHD than adults with only ADHD, as measured in side-effect scores, blood pressure, heart rate, and weight?

This was a retrospective study, using well-documented medical records, of the effects of drug treatment with methylphenidate (MPH), dexamphetamine (DEX), atomoxetine (ATX), bupropion, or modafinil.

The researchers compared 60 adults with comorbid ASD and ADHD to 226 adults with only ADHD. ADHD symptoms were scored using the Conners’ ADHD Rating Scale: Self Report–Short Version (CAARS: S-S). Side effects of ADHD medication were measured using either a 13-item or 20-item checklist with 4-point scales for item response. Researchers also tracked changes in body weight, blood pressure, and heart rate.

Following treatment, ADHD symptoms among the comorbid group declined by a quarter, and among the ADHD-only group by almost a third. There was no significant difference between men and women. Controlling for age, gender, and ADHD subtype, a comorbid diagnosis of ASD also did not significantly affect ADHD symptom reduction.

Turning to side effects, in the ADHD+ASD group, there were significant increases in decreased appetite and weight loss, and decreases in agitation, anxiety, and sadness/unhappiness. In the ADHD-only group, there were significant increases in decreased appetite, weight loss, and dry mouth, and decreases in sleeping disorder, nervousness, agitation, anxiety, and sadness / unhappiness. Yet there were no significant differences between the two groups. Side effects increased and decreased similarly in both. Likewise, there were no significant differences between the groups in changes in heart rate and blood pressure. The only significant difference in medication dosage was for bupropion, which was higher in the ADHD+ASD group, though without any sign of difference in side effects.

The authors concluded that this retrospective study “showed pharmacological treatment of adults with diagnoses of ADHD and ASD to be just as successful as the pharmacological treatment of adults with only ADHD,” but cautioned that “a randomized controlled trial should be conducted to evaluate the effectiveness and possible side effects of pharmacological treatment for ADHD in patients with ASD more reliably.”

REFERENCES
J. J. Muit, N. Bothof, and C. C. Kan, “Pharmacotherapy of ADHD in Adults With Autism Spectrum Disorder: Effectiveness and Side Effects,” Journal of Attention Disorders (2019) DOI: 10.1177/1087054719866255.

Are There Adverse Effects to Long-Term Treatment of ADHD with Methylphenidate?

Stephen V. Faraone, PhD on October 17, 2019

Methylphenidate (MPH) is one of the most widely-prescribed medications for children. Given that ADHD frequently persists over a large part of an individual’s lifespan, any side effects of medication initiated during childhood may well be compounded over time. With funding from the European Union, a recently released review of the evidence looked for possible adverse neurological and psychiatric outcomes.

From the outset, the international team recognized a challenge: “ADHD severity may be an important potential confounder as it may be associated with both the need for long-term MPH therapy and high levels of underlying neuropsychiatric comorbidity.” Their searches found a highly heterogeneous evidence base, which made meta-analysis inadvisable. For example, only 25 of 39 group studies reported the presence or absence of comorbid psychiatric conditions, and even among those, only one excluded participants with comorbidities. Moreover, in only 24 of 67 studies was the type of MPH used (immediate or extended-release) specified. The team, therefore, focused on laying out an “evidence map” to help determine priorities for further research.

The team found the following breakdown for specific types of adverse events:

  • Low mood/depression. All three noncomparative studies found MPH safe. Two large cohort studies, one with over 2,300 participants, the other with 142,000, favored MPH over the non-stimulant atomoxetine. But many other studies, including a randomized controlled trial (RCT), had unclear results. Conclusion: “the evidence base regarding mood outcomes from long-term MPH treatment is relatively strong, includes two well-powered comparative studies, and tends to favor MPH.”
  • Anxiety. Here again, all three noncomparative studies found MPH safe. But only two of seven comparative studies favored MPH, with the other five having unclear results. Conclusion: “while the evidence with regard to anxiety as an outcome of long-term MPH treatment tends to favor MPH, the evidence base is relatively weak.”
  • Irritability/emotional reactivity. A large cohort study with over 2,300 participants favored MPH over atomoxetine. Conclusion: “the evidence base … is limited, although it includes one well-powered study that found in favor of MPH over atomoxetine.”
    Suicidal behavior/ideation. There were no noncomparative studies, but all five comparative studies favored MPH. That included three large cohort studies, with a combined total of over a hundred thousand participants, that favored MPH over atomoxetine. Conclusion: “the evidence base … is relatively strong, and tends to favor MPH.”
  • Bipolar disorder. A very large cohort study, with well over a quarter-million participants, favored MPH over atomoxetine. A much smaller cohort study comparing MPH with atomoxetine, with less than a tenth the number of participants, pointed toward caution. Conclusion: “the evidence base … is limited and unclear, although it includes two well-powered studies.”
  • Psychosis/psychotic-like symptoms. By far the largest study, with over 145,000 participants, compared MPH with no treatment and pointed toward caution. A cohort study with over 2,300 participants favored MPH over atomoxetine. Conclusion: “These findings indicate that more research is needed into the relationship between ADHD and psychosis, and into whether MPH moderates that risk, as well as research into individual risk-factors for MPH-related psychosis in young people with ADHD.”
  • Substance use disorders. A cohort study with over 20,000 participants favored MPH over anti-depressants, anti-psychotics, and no medication. Other studies looking at dosages and durations of treatment, age at treatment initiation, or comparing with no treatment or “alternative” treatment, all favored MPH with the exception of a single study with unclear results. Conclusion: “the evidence base … is relatively strong, includes one well-powered study that compared MPH with antipsychotic and antidepressant treatment, and tends to favor MPH.”
  • Tics and other dyskinesias. Of four noncomparative studies, three favored MPH, the other, with the smallest sample size, urged caution. In studies comparing with dexamphetamine, pemoline, Adderall, or no active treatment, three had unclear results and two pointed towards caution. Conclusion: “more research is needed regarding the safety and management of long-term MPH in those with comorbid tics or tic disorder.”
  • Seizures or EEG abnormalities. With one exception, the studies had small sample sizes. The largest, with over 2,300 participants, compared MPH with atomoxetine, with inconclusive results. Two small studies found MPH safe, one had unclear results, and two others pointed towards caution. Conclusion: “While the evidence is limited and unclear, the studies do not indicate evidence for seizures as an AE of MPH treatment in children with no prior history … more research is needed into the safety of long-term MPH in children and young people at risk of seizures.”
  • Sleep Disorders. All three noncomparative studies found MPH safe, but the largest cohort study, with over 2,300 participants, clearly favored atomoxetine. Conclusion: “more research is needed into the relationship between ADHD, sleep, and long-term MPH treatment.”
  • Other notable psychiatric outcomes. Two noncomparative studies, with 118 and 289 participants, found MPH safe. A cohort study with over 700 participants compared with atomoxetine, with inconclusive results. Conclusion: “there is limited evidence regarding long-term MPH treatment and other neuropsychiatric outcomes and that further research may be needed into the relationship between long-term MPH treatment and aggression/hostility.”

Although this landmark review points to several gaps in the evidence base, it mainly supports prior conclusions of the US Food and Drug Administration (FDA) and other regulatory agencies (based on short-term randomized controlled trials) that MPH is safe for the treatment of ADHD in children and adults. Give that MPH has been used for ADHD for over fifty years and that FDA monitors the emergence of rare adverse events, patients, parents, and prescribers can feel confident that the medication is safe when used as prescribed.

REFERENCES:
Helga Krinzinger, Charlotte L Hall, Madeleine J Groom, Mohammed T Ansari, Tobias Banaschewski, Jan K Buitelaar, Sara Carucci, David Coghill, Marina Danckaerts, Ralf W Dittmann, Bruno Falissard, Peter Garas, Sarah K Inglis, Hanna Kovshoff, Puja Kochhar, Suzanne McCarthy, Peter Nagy, Antje Neubert, Samantha Roberts, Kapil Sayal, Edmund Sonuga-Barke , Ian C K Wong , Jun Xia, Alexander Zuddas, Chris Hollis, Kerstin Konrad, Elizabeth B Liddle and the ADDUCE Consortium, “Neurological and psychiatric adverse effects of long-term methylphenidate treatment in ADHD: A map of the current evidence,” Neuroscience and Biobehavioral Reviews (2019) DOI: https://doi.org/10.1016/j.neubiorev.2019.09.023

Trigeminal Nerve Stimulation May be an Effective Non-Drug Treatment for ADHD

Stephen V. Faraone, PhD on April 23, 2019

A team at the University of California at Los Angeles (UCLA) has just reported on the first-ever, double-blinded, sham-controlled study of trigeminal nerve stimulation (TNS) for treating ADHD. The trigeminal nerve is the largest cranial nerve. It enables facial sensation, as well as biting and chewing.

Over a four-week period, researchers fitted 62 eight-to-twelve-year-old children with electrodes while they slept; 32 got an active low current, the rest none at all. The active and sham setups were identical in appearance. The children were told, “pulses may come so fast or so slowly that the nerves in the forehead might or might not detect a sensation.” At the conclusion of the four weeks, there was an additional blinded week without intervention.

The primary efficacy outcome measure was the clinician-completed ADHD-RS total score, derived from parent interviews and available clinical information. It was completed at the onset of the study, and repeated over subsequent weeks. The Clinical Global Impression (CGI) score was used as a secondary outcome measure.

Both groups of children showed significant reductions in ADHD symptoms over the first week. But scores leveled off during the remaining three weeks for the group with sham treatment, while scores continued to decline for those in the group with actual stimulation. The standardized mean difference (SMD) between groups was 0.5.

By the conclusion of week 4, 52 percent for those in active treatment were improved or very much improved as indicated by CGI scores; only 14 percent did as well with the sham treatment. The number needed to treat was just 3.

After discontinuation of treatment, total scores in both groups rose at similar rates. At the end of week 5, CGI ratings for active treatment showed 13 percent improvement over baseline, versus 7 percent for sham treatment. The SMD was 0.46, once again indicating persistence of a medium effect size a week after treatment cessation.

The effect sizes computed for TNS are roughly comparable to effect sizes for nonstimulant medication, but less than those for stimulants.

Though the active group had significant gains in weight and pulse over the sham group, there were no serious adverse events in either group.

The authors concluded: “Results from the Early Impressions Questionnaire showed no differences in outcome expectations between treatment groups after 1 week using the randomized device, suggesting that our sham procedures successfully accomplished double blinding of group assignment. Improvements seen in the active and sham groups at week 1 likely reflect some placebo response secondary to the high level of parental involvement in administering treatment. Nonetheless, further improvement over subsequent weeks with active TNS suggests the emergence of true treatment effects … TNS is a non-medication minimal risk intervention with proven efficacy in alleviating ADHD symptoms. Although the present study finds that only slightly more than half of those receiving therapy have clinically meaningful improvement, the virtual lack of significant side effects should make it a popular treatment choice for many patients with ADHD, particularly for parents who prefer to avoid psychotropic medication.”

Nevertheless, one must keep in mind that this is a single un-replicated study with a small sample size. Further studies with larger numbers of participants are needed, both to confirm efficacy and to further explore the weight gains and higher pulse rates in the treatment group.

REFERENCES

James J. McGough, MD, Alexandra Sturm, PhD, Jennifer Cowen, PhD, Kelly Tung, BS, Giulia C. Salgari, MS, Andrew F. Leuchter, MD, Ian A. Cook, MD, Catherine A. Sugar, PhD, Sandra K. Loo, PhD, “Double-Blind, Sham-Controlled, Pilot Study of Trigeminal Nerve Stimulation for Attention-Deficit/ Hyperactivity Disorder,” Journal of the American Academy of Child & Adolescent Psychiatry, Vol. 58, No. 4 (April 2019), 403-411.

Are Shared Care Models Effective in Treating Childhood ADHD?

Stephen V. Faraone, PhD on July 12, 2018

A systematic review found five studies that evaluated shared care models involving children and adolescents, in which primary care providers (PCPs) collaborated with mental health care providers in treating ADHD. The 655 participants ranged in age from 5 to 17.

Two of the studies were randomized. In one, the largest, with 321 participants, care managers acted as liaisons between PCPs and psychiatrists, and provided psychoeducation and skills training for families. Effect sizes on the Vanderbilt ADHD Diagnostic Teacher Rating Scale were very small, ranging from a standardized mean differences (SMDs) of 0.07 to 0.12. Improvement on the Clinical Global Impression scale was also small (SMD = 0.3) and was not significant (p = 0.4).

In the other randomized study, with 63 participants, care managers also acted as liaisons between PCPs and a psychiatric decision support panel to provide Positive Parenting Training. The SNAP-IV hyperactivity/impulsivity score showed a medium effect size (SMD = 0.7), with a medium-to-large effect size (0.7) for improvement in social skills. The score difference for SNAP-IV inattention was not statistically significant.

The other three studies followed groups of individuals over time. In one cohort with 129 participants, PSPs consulted with psychiatrists by telephone; an evaluation, where necessary, performed within 4 weeks. As assessed by the Clinical Global Impression–Severity scale, symptoms declined from moderately severe to mild or borderline. On the Children’s Global Assessment Scale, there was improvement from problems in more than one area of functioning to just one area.

In another cohort with 116 participants, care managers acted as liaisons between pediatricians and a psychiatrist, and provided education to parents. Just over a quarter of participants showed improvement of greater than one standard deviation on the Vanderbilt ADHD Diagnostic Parent Rating Scale, and just under one in seven on the Vanderbilt ADHD Diagnostic Teacher Rating Scale.

The remaining cohort had only 26 participants. It offered PCPs access to outpatient psychiatric consultations within three weeks. PCPs reported a high level of satisfaction with their improved skills in mental health care. There was no evaluation of effect on symptoms.

With varied study designs, methodologies, and outcomes, the authors of the review could only conclude “that PCP collaboration with psychiatrists may be associated with increased comfort level. However, the association with symptom outcome and increased capacity was variable.” Given that randomized studies report only small effects, these shared care models cannot be routinely recommended.

REFERENCES
Meshal A. Sultan, Carlos S. Pastrana, and Kathleen A. Pajer, “Shared Care Models in the Treatment of Pediatric Attention-Deficit/Hyperactivity Disorder (ADHD): Are They Effective?” Health Services Research and Managerial Epidemiology, vol. 5, 1-7 (2018).

Identifying and Treating Persons with Comorbid ADHD and Substance Use Disorders

Stephen V. Faraone, PhD on May 6, 2018

An international group of twelve experts recently published a consensus report examining the state of the evidence and offering recommendations to guide screening, diagnosis, and treatment of individuals with ADHD-SUD comorbidity.1

In a clear sign that we are still in the early stages of understanding this relationship, five of the thirteen recommendations received the lowest recommendation grade (D), eight received the next-lowest (C), and none received the highest (A and B).

The lower grades reflected the absence of the highest level of evidence, obtained from meta-analyses or systematic reviews of relevant randomized controlled trials (RCTs).

Nevertheless, with these limitations in mind, the experts agreed on the following points:

ADHD Diagnosis

  • The strongest recommendation, the only one based on a 2+ level of evidence (well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal) is that the “Short Version of the Adult ADHD Self-Report Scale (ASRS-SV) screener is currently the most widely used and investigated screening tool in individuals with ADHD and comorbid SUD, with good sensitivity and specificity across studies.”
  • Two other recommendations were graded C: The diagnostic process should include current and past substance abuse and seek to involve partners and relatives in evaluating symptoms and functional impairments.
  • Four recommendations got the lowest grade, D. The experts suggested starting the diagnostic process as soon as possible and focusing on drug- and alcohol-free periods in the patient’s life during history taking. They also recommended that physicians and clinical psychologists should only make diagnoses if they have extensive training in diagnosing ADHD, as well as experience with adults with ADHD and with addiction care, and that they should consider treating adults with sufficiently severe ADHD symptoms.

ADHD Treatment

  • In general, evidence was stronger in this area, and only one of the six recommendations was graded D. The other five recommendations were graded C, with the highest level of evidence being 2 (cohort or case and control studies with undetermined risk of bias), although in three cases it was level 3 (non-analytical studies, such as case reports and case series).
  • The grade D recommendation was to always consider a combination of psychotherapy and pharmacotherapy.
  • The grade C recommendations included considering adequate medical treatment of both ADHD and SUD; integrating ADHD treatment with SUD treatment as soon as possible; considering psychotherapy targeting both; use of long-acting methylphenidate, extended-release amphetamines, and atomoxetine because of their low potential for abuse; and careful clinical management to avoid abuse and diversion of prescribed stimulants.

Note: Andrew Reding is a co-author on this post.

REFERENCES
1Cleo L. Crunelle at al., “International Consensus Statement on Screening, Diagnosis and Treatment of Substance Use Disorder Patients with Comorbid Attention Deficit/Hyperactivity Disorder,” European Addiction Research, published online March 6, 2018, DOI: 10.1159/000487767.

Mindfulness-Based Cognitive Therapy for Adults with ADHD

Stephen V. Faraone, PhD on April 6, 2018

A Dutch study compared the efficacy of mindfulness-based cognitive therapy (MBCT) combined with treatment as usual (TAU), with TAU-only as the control group. MBCT consisted of an eight-week group therapy consisting of mindfulness exercises (bodyscan, sitting meditation, mindful movement), psychoeducation about ADHD, and group exercises. TAU consisted of usual treatment in the Netherlands, including medications and other psychological treatment. Sixty individuals were randomly assigned to each group. MBCT was taught in subgroups of 8 to 12 individuals. Patients assigned to TAU were not brought together in small groups. Baseline demographic and clinical characteristics were closely matched for both groups.

Outcomes were evaluated at the start, immediately following treatment, and again after 3 and 6 months using well-validated rating scales. Following treatment, the MBCT + TAU group outperformed the TAU group by an average of 3.4 points on the Conners’ Adult Rating Scale, corresponding to a standardized mean difference of .41. Thirty-one percent of the MBCT + TAU group made significant gains, versus 5% of the TAU group. 27% of MBCT +TAU patients scored a symptom reduction of at least 30 percent, as opposed to only 4% of TAU patients. Three and six-month follow-up effects were stable, with an effect size of .43.

The authors concluded “that MBCT has significant benefits to adults with ADHD up to 6 months after post-treatment, with regard to both ADHD symptoms and positive outcomes.” Yet in their section on limitations, they overlook a potentially important one. There was no active placebo control. Those who were undergoing TAU-only were aware that they were not doing anything different from what they had been doing before the study. Hence no substantial placebo response would be expected from this group during the intervention period (post-treatment they were offered an opportunity to undergo MBCT). Moreover, MBCT + TAU participants were gathered into small groups, whereas TAU participants were not. We therefore have no way of knowing what effect group interaction had on the outcomes, because it was not controlled for. So, although these results are intriguing and suggest that further research is worthwhile, the work is not sufficiently rigorous to definitively conclude that MBCT should be prescribed for adults with ADHD.

Note: This post was co-authored by Andrew Reding.

REFERENCES
Janssen L, Kan CC, Carpentier PJ, Sizoo B, Hepark S, Schellekens MPJ, Donders ART, Buitelaar JK, Speckens AEM. “Mindfulness-based cognitive therapy v. treatment as usual in adults with ADHD: a multicentre, single-blind, randomised controlled trial,” Psychological Medicine (2018), https:// doi.org/10.1017/S0033291718000429

Is Cognitive Behavioral Therapy Effective for Older Adults with ADHD?

Stephen V. Faraone, PhD on March 6, 2018

Though there have been numerous studies of the efficacy of cognitive behavioral therapy (CBT) for ADHD symptoms in children, adolescents, and adults, few have examined efficacy among adults over 50. A new study begins to fill that void.

Psychiatric researchers from the New York University School of Medicine, Massachusetts General Hospital, and Pfizer randomly assigned 88 adults diagnosed with elevated levels of ADHD to one of two groups. The first group received 12 weeks of CBT targeting executive dysfunction – a deficiency in the ability to properly analyze, plan, organize, schedule, and complete tasks. The second group was assigned to a support group, intended to serve as a control for any effects arising from participating in a group therapy. Each group was split into subgroups of six to eight participants. One of the CBT subgroups was run concurrently with one of the support-only subgroups and matched on the percent receiving ADHD medications.

Outcomes were obtained for different ADHD demographics, 26 adults aged 50 or older (12 in CBT and 14 in support) and compared with 55 younger adults (29 in CBT and 26 in support). The mean age of the younger group was 35 and of the older group 56. Roughly half of the older group, and 3/5ths of the younger group, was on medication. Independent (“blinded”) clinicians rated symptoms of ADHD before and after treatment.

In the blind structured interview, both inattentive scores and executive function scores improved significantly and almost identically for both older and younger adults following CBT. When compared with the controls (support groups), however, there was a marked divergence. In younger adults, CBT groups significantly outperformed support groups, with mean relative score improvements of 3.7 for inattentive symptoms and 2.9 for executive functioning. In older adults, however, the relative score improvements were only 1.1 and 0.9, and were not statistically significant.

Given the nonsignificant improvements over placebo, the authors’ conclusion that “The results provide preliminary evidence that CBT is an effective intervention for older adults with ADHD” is premature. As they note, a similar large placebo effect was seen in adults over 50 in a meta-analysis of CBT for depression, rendering the outcomes nonsignificant. Perhaps structured human contact is the key ingredient in this age group. It may also be, as suggested by the positive relative gains on six of seven measures, that CBT has a small net benefit over placebo, which cannot be validated with such a small sample size. Awaiting results from studies with larger sample sizes, it is for now impossible to reach any definitive conclusions about the efficacy of CBT for treating adults over 50.

Note: Andrew Reding is co-author on this post.

REFERENCES
Mary V. Solanto, Craig B. Surman, Jose Ma. J. Alvir, “The efficacy of cognitive–behavioral therapy for older adults with ADHD: a randomized controlled trial,” ADHD Attention Deficit and Hyperactivity Disorders (2018)

062617 ADHD Treatment Decision Tree

Stephen V. Faraone, PhD on June 25, 2017

If you’ve ever wondered how experts make treatment recommendations for patients with ADHD, take a look at this ADHD treatment decision tree that my colleagues and I constructed for our “Primer” about ADHD, http://rdcu.be/gYyV. Although a picture is worth a thousand words, keep in mind that this infographic only gives the bare bones of a complex process.   That said, it is telling that one of the first questions an expert asks is if the patient has a comorbid condition that is more severe than ADHD.  The rule of thumb is to treat the more severe disorder first and after that condition has been stabilized plan a treatment approach for the other condition.  Stimulants are typically the first line treatment due to their greater efficacy compared with non-stimulants.  When considering any medication treatment for ADHD, safety is the first concern which is why medical contraindications to stimulants, such as cardiovascular issues or concerns about substance abuse, must be considered.  For very young children (preschoolers) family behavior therapy is typically used prior to medication.  Clinicians also must deal with personal preferences.   Some parents and some adolescents and adults with ADHD simply don’t want to take stimulant medications for the disorder.  When that happens, clinicians should do their best to educate them about the costs and benefits of stimulant treatment.   If, as is the case for most patients, the doctor takes the stimulant arm of the decision tree, he or she must next decide if methylphenidate of amphetamine is more appropriate.  Here there is very little guidance for doctors.  Amphetamine compounds are a bit more effective but can lead to greater side effects.   Genetic studies suggest that a person’s genetic background provide some information about who will respond well to methylphenidate but we are not yet able to make very accurate predictions.    After choosing the type of stimulant, the doctor must next consider what duration of action is appropriate for each patient.  There is no simple rule here; the choice will depend upon the specific needs of each patient.  Many children benefit from longer acting medications to get them through school, homework and late afternoon/evening social activities.  Likewise for adults.  But many patients prefer shorter acting medications especially as these can be used to target specific times of day and can also lower the burden of side effects.   For patients taken down the non-stimulant arm of the decision tree, duration is not an issue but the patient and doctor must choose from among two classes of medications norepinephrine reuptake inhibitors or alpha-2-agonists.  There are not a lot of good data to guide this decision but, again, genetics can be useful in some cases.  Regardless of whether the first treatment is a stimulant or a non-stimulant, the patient’s response must be closely monitored as there is no guarantee that the first choice of medication will work out well.  In some cases efficacy is low or adverse events are high.  Sometimes this can be fixed by changing the dose and sometimes a trial of a new medication is indicated.  If you are a parent of a child with ADHD or an adult with ADHD, this trial and error approach can be frustrating.  But don’t lose hope.  In the end, most ADHD patients find a dose and a medication that works for them.   Last but not least, when medication leads to a partial response, even after adjusting doses and trying different medication types, doctors should consider referring the patient for a non-pharmacologic ADHD treatment.  You can read details about these in my other blogs but for here the main point is to find an evidenced-based treatment.  For children the biggest evidence base is for behavioral family therapy.  For adults, cognitive behavior therapy (CBT) is the best choice.   With the exception of preschoolers, the experts I worked with on this infographic did not recommend these therapies before medication treatment.  The reason is that the medications are much more effective and many non-pharmacologic treatments (such as CBT) have no data indicating they work well in the absence of medication.  

REFERENCE

Faraone, S. V. et al. (2015) Attention-deficit/hyperactivity disorder Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.20 ;  http://rdcu.be/gYyV

ADHD Treatment Decision Tree

Stephen V. Faraone, PhD on June 25, 2017

If you’ve ever wondered how experts make treatment recommendations for patients with ADHD, take a look at this ADHD treatment decision tree that my colleagues and I constructed for our “Primer” about ADHD, http://rdcu.be/gYyV. Although a picture is worth a thousand words, keep in mind that this infographic only gives the bare bones of a complex process.   That said, it is telling that one of the first questions an expert asks is if the patient has a comorbid condition that is more severe than ADHD.  The rule of thumb is to treat the more severe disorder first and after that condition has been stabilized plan a treatment approach for the other condition.  Stimulants are typically the first line treatment due to their greater efficacy compared with non-stimulants.  When considering any medication treatment for ADHD, safety is the first concern which is why medical contraindications to stimulants, such as cardiovascular issues or concerns about substance abuse, must be considered.  For very young children (preschoolers) family behavior therapy is typically used prior to medication.  Clinicians also must deal with personal preferences.   Some parents and some adolescents and adults with ADHD simply don’t want to take stimulant medications for the disorder.  When that happens, clinicians should do their best to educate them about the costs and benefits of stimulant treatment.   If, as is the case for most patients, the doctor takes the stimulant arm of the decision tree, he or she must next decide if methylphenidate of amphetamine is more appropriate.  Here there is very little guidance for doctors.  Amphetamine compounds are a bit more effective but can lead to greater side effects.   Genetic studies suggest that a person’s genetic background provide some information about who will respond well to methylphenidate but we are not yet able to make very accurate predictions.    After choosing the type of stimulant, the doctor must next consider what duration of action is appropriate for each patient.  There is no simple rule here; the choice will depend upon the specific needs of each patient.  Many children benefit from longer acting medications to get them through school, homework and late afternoon/evening social activities.  Likewise for adults.  But many patients prefer shorter acting medications especially as these can be used to target specific times of day and can also lower the burden of side effects.   For patients taken down the non-stimulant arm of the decision tree, duration is not an issue but the patient and doctor must choose from among two classes of medications norepinephrine reuptake inhibitors or alpha-2-agonists.  There are not a lot of good data to guide this decision but, again, genetics can be useful in some cases.  Regardless of whether the first treatment is a stimulant or a non-stimulant, the patient’s response must be closely monitored as there is no guarantee that the first choice of medication will work out well.  In some cases efficacy is low or adverse events are high.  Sometimes this can be fixed by changing the dose and sometimes a trial of a new medication is indicated.  If you are a parent of a child with ADHD or an adult with ADHD, this trial and error approach can be frustrating.  But don’t lose hope.  In the end, most ADHD patients find a dose and a medication that works for them.   Last but not least, when medication leads to a partial response, even after adjusting doses and trying different medication types, doctors should consider referring the patient for a non-pharmacologic ADHD treatment.  You can read details about these in my other blogs but for here the main point is to find an evidenced-based treatment.  For children the biggest evidence base is for behavioral family therapy.  For adults, cognitive behavior therapy (CBT) is the best choice.   With the exception of preschoolers, the experts I worked with on this infographic did not recommend these therapies before medication treatment.  The reason is that the medications are much more effective and many non-pharmacologic treatments (such as CBT) have no data indicating they work well in the absence of medication.  

 

REFERENCE

Faraone, S. V. et al. (2015) Attention-deficit/hyperactivity disorder Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.20 ;  http://rdcu.be/gYyV

The Goal of ADHD Diagnosis? Safe and Effective Treatment

Stephen V. Faraone, PhD on June 15, 2017

The diagnosis of ADHD should only be done by a licensed clinician and that clinician should have one goal in mind: to plan a safe and effective course of evidenced-based treatment.  The infographic below gives a summary of this diagnostic approach over time, which my colleagues and I prepared for our “Primer” about ADHD, referenced below.

   A key point that parents of ADHD youth and adults with ADHD should keep in mind is that there is only one way to diagnose ADHD.  An expert clinician must document the criteria for the disorder as specified by either the Diagnostic and Statistical Manual of the American Psychiatric Association, which is now in its fifth edition (DSM-5) or the World Health Organizations International Classification of Diseases (ICD-10).  The two sets of criteria are nearly identical.  These criteria are most commonly applied by a clinician asking questions of the parent (for children) and/or patient (for adolescents and adults).  For children, information from the teacher can be useful.  Some clinicians get this information by having the parent ask the teacher to fill out a rating scale.  This information can be very useful if it is available.   

When diagnosing adults, it is also useful to collect information from a significant other which can be a parent for young adults or a spouse for older adults.  But when such informants are not available, diagnosing ADHD based on the patient’s self-report is valid.  As the infographic indicates, any diagnosis of ADHD should also assess for comorbid psychiatric disorders as these have implications for which ADHD medications will be safe and effective.  And because a prior history of cardiovascular disease or seizures frequently contraindicate stimulants, these must also be assessed.

 

REFERENCE

Faraone, S. V. et al. (2015) Attention-deficit/hyperactivity disorder Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.20 ;  http://rdcu.be/gYyV