What steps should clinicians take if psychopharmacologic treatments and school behavioral strategies are insufficient for managing a child with ADHD? We've all been there. ADHD, attention deficit hyperactivity disorder, of course, affects millions of children and adolescents worldwide and can significantly impact focus, impulses, and engagement with friends.

Parents and caregivers need to understand the different kinds of medications and therapies that are available to help manage ADHD. In this podcast, Mara and I will explore the various treatment options for ADHD in children and discuss how to navigate the process of selecting more effective treatments.

Published On: 04/22/2024

Duration:  26 minutes, 43 seconds

Transcript:

JOSH FEDER: When we first recorded this podcast, which has been in the can for a while, it was a somewhat different situation, even just a year and a half ago, that underlines how much medicine changes. So, you'll hear in this podcast changes in our voices because we've stripped out and added in things to bring this podcast up to date. And again, that underlines how medicine changes so fast. That even knowing something one year, you don't necessarily know it two years from now, and a really good reason to keep continuing education, cycling through different topics so that we don't stay behind I'm Dr. Josh Feder the editor-in-chief of The Carlat Child Psychiatry Report and co-author of the newly released second edition of the Child Medication Factbook for Psychiatric Practice. 

MARA GOVERMAN: I'm Mara Goverman, a licensed clinical social worker in Southern California with a private practice and an avid reader of The Carlat Reports. 

JOSH FEDER: So, what we're going to do is we're going to talk through our recently published algorithm in the Child Medication Factbook for Psychiatric Practice and give you our go-by of how we approach ADHD. 

MARA GOVERMAN: So, Dr. Feder, where do we begin our discussion? Well, look, when you get somebody in and you've done presumably a decent assessment for ADHD, we're not going to go through all the nuts and bolts of that now.

JOSH FEDER: You start with psychoeducation and behavioral parent training, such as Triple P, Incredible Years, P. M. T. P. C. I. T. (for preschool to preteen age children). These are evidence-based approaches for helping parents to help kids to be more able to know what they need to do when they need to do it and to do it in a collaborative, nonpunitive way. Understanding ADHD is part of who you are. As you know, we're talking about autism, not as Autism Spectrum Disorder, but as autism or autistic people, neurodiversity and a lot of people think of ADHD that same way. Now, it's kind of how you're built, how you're wired, and instead of calling it a disorder, I know we have to for insurance purposes, but instead of thinking about it, is there something wrong with you? Let's think about it as this is how you're wired and let's see how we work with it. And these kinds of approaches done, right help people. Understand, if you can figure out who you are and how you work, you can function better in the world and you can help your kid function better in the world. 

MARA GOVERMAN: So you're talking about acceptance and compassion for people's differences. 

JOSH FEDER: Well, that's right. And then once you've done that, there are a couple of other pieces that are important to consider. If you remember our podcast with Russ Barkley a couple of years ago, he talked about how just having ADHD, you might be a little bit less organized and more likely to suffer from chronic diseases that could reduce your lifespan. And his recommendation was, you should be considering stimulant treatment. In addition to that, thinking about school collaboration. So helping the school to also appreciate the child or teen as someone who's neurodiverse in their way and looking at accommodations and interventions, 504 plans and individual educational plans, and the use of teacher rating skills to keep us appraised of how that child is doing at school. 

MARA GOVERMAN: Before we move on to the psychopharmacologic treatments, can you give our practitioners a timeline of how long one can anticipate working on psychoeducation, school collaboration, on co-parenting before we start moving into a psychopharmacologic treatment?

JOSH FEDER:  That's a great question. I think it depends partly on the severity of symptoms. If you have somebody who's struggling, but not failing that, I think putting some of these things in place, you give it a couple 3 months. I think the other challenge, of course, is finding someone competent to help you as a family. There's such a dearth of mental health practitioners who specialize in this or know it. Where do you find the good nuts and bolts stuff that works or people who are good at it? But knowing about these different kinds of approaches might make it easier for people to seek them out. For instance, incredible years, you can go on a website and probably find somebody who's a practitioner. Triple P, P. M. T, a little bit harder. P. C. I. T. (parent-child interactive therapy) you can probably go on a website for that as well and look for specific people, but I'd say 1 to 3 months if it's not urgent, if it's more urgent, I think you're more in a place where you need to be thinking more soon about things like stimulant medications. 

MARA GOVERMAN: So what steps should clinicians take if psychopharmacologic treatments and school and behavioral strategies are insufficient for managing a child with ADHD? What is the next step? 

JOSH FEDER: We think people should be considering starting with stimulants. And when we talk about those, we're talking about long-acting methylphenidate, such as methylphenidate ER capsules. They're like 50% immediate release, 50% sustained release, or dexmethylphenidate capsules or just the methylphenidate tabs, things like that. Why methylphenidate? Fewer side effects typically with that than with dextroamphetamine products. So we tend to try those first. 

MARA GOVERMAN: Is this also a good time to talk about when thinking about stimulants, blood pressure, weight, and dietary preferences?

JOSH FEDER: Absolutely. So part of your treatment is going to be monitoring blood pressure and pulse and sleep and appetite and certainly advising parents about making sure kids have been eating and hydrating during the day, or they may be very cranky later on. If you have some of these contraindications to stimulants and no other comorbidity happening, you might try guanine clonidine, the central alpha agonist, or go to Atomoxetine or Viloxazine. The kind of SNRI-like medications are like antidepressant cousins that have been approved for ADHD as well. If you have comorbid depression, you might try bupropion and if you've got insomnia, tics, PTSD, anxiety, or appetite concerns, then you're kind of back to [inaudable] and clonidine, the central alpha agonist. And remember with sleep, don't forget cognitive behavioral therapy for insomnia that picks apart the sleep hygiene ideas, but does it in a way that you can operationalize and work on them. Just plain sleep hygiene advice as we've talked about before in these podcasts. Usually, people know it and they don't do it unless you have a much more focused attempt to address it like with CBTI. 

MARA GOVERMAN: This also includes discussing with patients and parents about when to turn off electronics and TV before bedtime. 

JOSH FEDER: Absolutely. Exercise. All those kinds of things that we want kids doing. 

MARA GOVERMAN: Let's say there are no contraindications and you're trying methylphenidate and it's not working. 

JOSH FEDER: Plan B is a dextroamphetamine product. There are other things, that come up as well, right? So in the middle of a methylphenidate trial, you might get a kid who doesn't, swallow pills. And so you might be looking at a transdermal patch or, some other kind of suspension like a liquid you can swallow. If you end up with some side effects from the methylphenidate, sometimes if you go from long-acting to short-acting, and you can kind of titrate a little bit more through the day, that might be helpful. But, if you're failing, methylphenidate trials, try a long-acting amphetamine, dextroamphetamine-like, There are dexamphetamine capsules or dexamphetamine amphetamine ER capsules. 

MARA GOVERMAN: What are your thoughts when you've tried the amphetamines and they don't work? And how much time do you give to determine whether they're working or not?

JOSH FEDER: Good question. So for any of the stimulant medications, you kind of know in a few days whether a particular dose is working and it's helpful if you can be in touch with families kind of on a week-by-week basis. And then be bringing them in relatively frequently every few weeks for blood pressure checks and things like that. That'll help you to titrate, whether it's methylphenidate or dextroamphetamine. But if you've got limited effectiveness from your amphetamine-type products, then you might try adding an alpha agonist like guanfacine or clonidine. And that may that combination is often very helpful. 

MARA GOVERMAN: If the clinician notices that severe aggression concerns remain, one can try Risperidone or Valproate. Yes? 

JOSH FEDER: Yeah, you want to titrate the stimulants first, because about 60% maybe 80% of the time, you can handle aggression with ADHD with stimulants. So we don't want to just jump to Risperdal or Valproate, but those 2 are the ones with the evidence base for effectiveness. Of course, all the caveats with Risperidone are there, right? I mean, we worry a lot about metabolic problems. And so you're checking lipids and hemoglobin A1c and other labs as indicated at baseline, then at 12 weeks, then annually, or sooner if indicated. You're checking an abnormal involuntary movement scale at baseline and every 6 months or sooner if you're seeing something happening, and you need to consider getting an EKG at baseline and annually with Risperdal or any 2nd generation antipsychotic as well, and valproate is valproate, that has valproate, has potential for hepatic toxicity, pancreatitis. You have to watch the levels on that too. So you just want to be a little bit persnickety about watching these things if you're going to be using them for aggression. But, rather than casting about for lots of different ideas, try these things 1st. One stimulant titrated, if that doesn't work, another kind of stimulant titrated, go through a couple of trials of those and then yes, Risperdal or Valproate. 

MARA GOVERMAN: I guess most parents would want to know, do patients outgrow these medications? Do you ever discontinue them? And what are the indications for when you should be looking at that? 

JOSH FEDER: Right, so in ADHD, several people settle down, they're not as impulsive, especially when they've hit their late teens and early 20s, we think that may have something to do with myelination of your prefrontal cortex and they look a lot calmer and there are plenty of people who set aside their medications, whether it's stimulants or the atom oxygen like medicines or the central alphas, and including for Risperdal and valproate. So kids often settle down in their teens and early twenties, and we'd love to see that. In fact, for any person on medication. I think it's a fair question of how long do they need to be on it. We see kids who are growing and they seem to grow out of their doses and seem to need a little bit more of all these medications. So we titrate based on that. But for a kid who's stable for 6 to 12 months, I'm always asking, can we be reducing or discontinuing? Are they doing better? And I think it is appropriate and ethically important to be having these ongoing discussions. Relatively few people want to be on medicine. However, if as you're going down and go down relatively slowly, you don't just stop the medicine, but titrate down maybe by at most 25% over a couple of months. And then another 25%, if you're seeing deterioration, well, usually you go back up and you hold it steady and then maybe try again another year later. What I've found is that lots of times, over the years, you have people who can come off and people who don't. That's just how that unfolds. 

MARA GOVERMAN: Do you have any words of wisdom for clinicians who have clients who are going off to college who are taking stimulants? 

JOSH FEDER: I mean, that's something we need to start thinking about years before anybody goes away, right? You need to be able to do laundry, find food, and get yourself to sleep. Knowing how to take your medications, and how do you get them from the pharmacy? We had a piece on that in the college on psychiatry report a little while back that people can reference that goes into it in some depth. But if you don't know how to take your medicine. You may have a lot more trouble organizing yourself, getting your work done, and making it in college. Think about this as being out there on your own and not taking care of yourself, which includes not taking the medicine that you need to help you take care of yourself. What a what a difficult conundrum to be in, right? 

MARA GOVERMAN: Yes, and as a practitioner, we think about that executive function piece and being able to balance all of the stimulation that comes along with a freshman, which is sleep, socializing, organizing classes, getting there. There's so much that goes into a successful year, and those are things that a therapist would benefit from talking to their clients about. 

JOSH FEDER: Stimulants have street value and if nothing else, get a lockbox and you get a cable for it and you tie the thing to your bed frame or you lock it to your bed frame and put your wallet and your keys and your stimulant medications in there and you don't make a big deal of having them so that you don't have people breaking in and taking your medication because replacing it may be difficult. Yeah, and the other thing is just the decision-making, right? Are you going to go out with your friends? Are you going to use substances? All those things. People can make better decisions when they're sticking with their ADHD medication.  

MARA GOVERMAN: And have a plan. Discussing what's your plan, and the limits of boundaries so that there's an awareness instead of being overwhelmed or surprised in many new situations. As a psychiatrist, what's the bottom line that's most important to you on this topic? 

JOSH FEDER: My biggest decision point is whether somebody can be away at college and be okay, meaning they can come back and see me every 3 to 6 months. And I can refill their medicine and state laws are going to vary about what you are and aren't allowed to do in terms of being a doctor and treating someone from far away. But for the most part, I think most people are covered if the kid is domiciled at home, but it's a way for college. Nobody makes a big deal about it, but, if the kid's not stable enough for that, that's when you get into trouble. So think about this for planning. You need to think about whether somebody needs a psychiatrist or other prescriber at school or near school, a therapist at school or near school, and you've got to plan for that and get it set up. That's not easy to do for a whole lot of reasons. The first is that there's a shortage of mental health providers in the first place. The second is that a lot of people aren't going to want to establish a relationship before you're actually in town. And then the other piece is, that some people seem like they're ready, but then they get to school and the wheels fall off. Then you're scrambling around looking for care or you're deciding, do we have to bring this person back for a day, a week, a month, a semester, forget the whole thing, and stay at home and think about how sad that can feel. Feeling like kind of a failure sometimes. So there's a lot to consider, and I'd say the biggest inflection point, if you will, is getting it right about whether you need help at school. And if you're going to need help at school, are you ready to go away? That's another question. On the other hand, if you don't give it a try, are you ever going to launch? So there's so much, at stake a lot of times. In most American culture, a lot of it anyway, the goal is to grow up, learn something that you can do, get a job and go take care of yourself, pay your bills find your place, and maybe have a relationship and start your own family. But the idea is that you're going to be independent of your family of origin, right? That's not true in a lot of ways, right? One is that a huge percentage. At post-college age, kids are back to living right at home, which is very similar to a lot of cultures. I think of Panama and other countries where kids live at home until they get married. It's also different from a lot of subcultures and you can't just presume. That the family that somebody is in is aiming to have a kid out and independent. I think financially that's often a goal for some people, but not necessarily. There are a lot of families for whom the goal isn't independence. It's what can this person do to help the family and maybe getting a career will help the family. It's not that they're going to be independent and self-actualize. It's that the family is going to be supported as a unit. And so you got to be careful not to make judgments based on perhaps your own family of origin or values that you've grown up with. 

MARA GOVERMAN: As a prescribing doctor with boots on the ground, what is it like for you and your clients in light of the medication shortages that are being reported? 

JOSH FEDER: Well, they're not just reported. I mean, we are living this every day. Okay, so a few years ago, you would write a script on a triplicate by hand, and at least if one pharmacy didn't have the stuff, They could go to another pharmacy, but shortages weren't that big a deal 5, 6 years ago, now that most of us are required to do electronic prescriptions, at least for my platform, you put the thing in, you use your extra verification because it's a controlled substance, and then you find out a few days later that the pharmacy doesn't have what it is, and it could be something as simple as, generic, so dextroamphetamine salts extended release, a. k. a. Adderall XR, right? It could be something fancy like Vyvanse or Drené. It used to be that the fancier stuff that was more expensive would be maybe in better supply because people didn't want to pay for it. Now that stuff, people kind of all pivot to, maybe Vyvanse, and then that's all gone, and then you're pivoting back to Adderall XR, or pivoting from dextroamphetamine back again, just because you're searching for some stimulant for somebody who's responded well to it, and lots of times after figuring out which kind of packaging they respond to because not everybody responds as well to one stimulant or another, one kind of packaging or another, and then, at least for me, I have to change. The default for all their prescriptions in my platform. Every time we discover something, we want to try it at yet another pharmacy. And then who's going to make all those calls to the pharmacy, right? So, sometimes patients will do it, but a lot of times the pharmacies won't tell a patient what they have. They want the doctor to call. Well, I'm going to call 5 pharmacies. Sometimes you call a chain and they'll tell you. Okay. If there's some of it somewhere in the county, sometimes they won't and sometimes they'll tell you that maybe they have something somewhere. You call that place to be sure, and they don't have it or the patient calls and says they have what I need. They told me they had what I needed at whatever pharmacy. But, I'm with patients right now and I get that message 2 hours later. Are they still going to have it? I don't know. So it's, it's everybody running around scurrying to try to get these. These medications are now in such short supply, especially since the pandemic, which seems to have done. A couple of things. One is it's made more clear that it's hard to focus when you're online and maybe maybe that's ADHD sometimes or exacerbated by the online environment, or maybe it's one of the impacts of the covid infection itself, which we think is one of the things that happens almost like a mild encephalitic response that gives you ADHD symptoms, which, which are responsive to stimulants. So for lots of different reasons, we have more people perhaps appropriately benefiting from stimulants, and more people who believe they have ADHD wanting stimulants. And then we've got the manufacturers who haven't been given the right to make more of what they could make. And my understanding is that some of them are not even making it. Producing the limit of what they could make to sell. So here we've got this major shortage and we're all scurrying about and it's a real pain in the neck.

MARA GOVERMAN: So there you have it. When choosing a stimulant, the first decision is between an amphetamine or methylphenidate preparation. More recent data have suggested that, based on safety and efficacy, methylphenidates are a better choice for kids and adolescents, whereas amphetamine class agents are better in adults. Yet, even in adults, we generally recommend going with the methylphenidate preparation first based on lower side effects and misuse potential. 

JOSH FEDER: The second decision is choosing between a long-acting or short-acting stimulant. For kids who don't like swallowing pills, there are various options. Some long-acting stimulants can be opened or sprinkled on food. There are also short and long-acting liquid, chewable, and disintegrating brand name options, though they are expensive and often require pre-authorization. 

MARA GOVERMAN: Finally, another option for the pill phobics is the Datrana or Xelstrym patch. When initiating a trial of stimulant medication, titrating the dose every week optimizes the response efficiently, with the added benefit of limiting the use of additional medications with their associated side effects. While valproate and risperidone have been demonstrated to be effective for aggression with ADHD, you will rarely need them if you prioritize stimulant titration. 

JOSH FEDER: ADHD is under-recognized probably more than it's overdiagnosed and therefore under-treated. More than it's over-treated the treatment starts with structuring your life in a way that makes things work better, putting your keys in the same place or everything else so that you know where it is, but medication truly makes a difference, and being able to take care of yourself when there's side effects, we can usually figure out ways to manage them as well. And if you can't do that as an adult, whether you're a young adult or, older, and you need somebody to help you, it's okay to have somebody helping you do that so that everybody functions better. We're not meant to live isolated lives. We're meant to live interdependently. So, learn to surf your ADHD along with other people, just like I hope you'll accept other people who're bothering you about the things you need to do, like, remember your medication and appreciate them for it, rather than give them a hard time about it. And everybody will be happier and more functional. We can enjoy each other. including our differences. The algorithm is available for people to read in The Carlat Medication Factbook for Psychiatric Practice Second Edition available now. Hopefully, you'll get a copy of it and check out all our algorithms. For those of you who are Carlat Child Psychiatry Report subscribers, you'll get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits that support the algorithms that we talked about today.

MARA GOVERMAN: Everything from Carlat Publishing is independently researched and produced. There's no funding from the pharmaceutical industry. 

JOSH FEDER: Yes. The newsletters and books we produce depend entirely on reader support. There are no ads and our authors don't receive industry funding that helps us to bring you unbiased information that you can trust. 

MARA GOVERMAN: Thanks for listening and have a great day.

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The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.