ADHD Diagnosis a Detective's Job

An Expert Interview With Julie Dopheide, PharmD, BCPP

Jim Kling

April 12, 2011

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 Julie 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.

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