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Children, adults, patients with substance use disorders can receive appropriate diagnosis, treatment for ADHD

Thursday, December 13 2007 | Comments
Evidence Grade 0 What's This?
Clinicians can successfully make a diagnosis of and manage attention-deficit/hyperactivity disorder in special groups, such as preschoolers, adults, and patients with substance use disorders, according to a panel of experts.

Dr. Christopher Kratochvil, assistant director of the Psychopharmacology Research Consortium at the University of Nebraska Medical Center, explained that ADHD is very much a lifelong disorder. He focused his presentation on preschoolers and adults who have ADHD.

He noted that a "comprehensive assessment of what's going on with these [preschoolers]" should be done by clinicians who know what is developmentally appropriate, "because until they have that kind of experience, how are they going to know what's inappropriate?"

Similarly, he noted that many clinicians may be reluctant to make a diagnosis of ADHD in adults, because they may have little experience or training to do so.

Dr. Kratochvil emphasized that the DSM-IV criteria for ADHD in adults and children are actually the same, but the clinical presentation is different. Both he and Dr. Jefferson Prince, director of child psychiatry for North Shore Medical Center in Salem, Mass., noted that inattention is the ADHD symptom that is most commonly exhibited in adulthood.

For making the diagnosis in both preschoolers and adults, Dr. Kratochvil advised doing clinical interviews with the patients and significant people around them, such as parents and/or spouses. Past and present functioning in day care, school, or work settings should be reviewed; also, ADHD symptoms can be assessed by using interviews and rating scales, such as the Adult ADHD Self-Report Scale that aids in adult ADHD diagnosis and treatment. Clinicians also need to explore potential comorbidities and differential diagnoses.

As far as using pharmacotherapy to treat preschoolers, Dr. Kratochvil said that only d-amphetamine is approved to treat children aged 3 years or older, an approval that is based on only an open-label report and not on controlled data. Other pharmacotherapies are only approved for children aged 6 years or older.

However, he noted that methylphenidate is the drug that has been studied most often in double-blind, placebo-controlled trials among preschoolers. Dr. Kratochvil cited PATS data showing that methylphenidate immediate-release (2.5 mg, 5 mg, or 7.5 mg) given 3 times daily significantly reduced ADHD symptoms in patients aged 3 to 5.5 years.

He also announced results from a new open-label trial indicating that up to 1.8 mg/kg of atomoxetine given daily significantly reduced the total ADHD-IV Rating Scale score when it was administered to 22 children aged 5 to 6 years (P<.001). However, 12 patients had emotional lability and 11 experienced decreased appetite.

Dr. Kratochvil also advised that children's growth be monitored longitudinally and individually by using growth charts, such as those available from the Centers for Disease Control and Prevention.

To treat adults with ADHD, the Food and Drug Administration has approved atomoxetine, d-methylphenidate extended-release, and mixed amphetamine salts extended-release. Dr. Kratochvil advised that clinicians have maintenance visits with their patients to monitor drug effectiveness, tolerability, and compliance.

"And in the end, what we end up doing is looking at the risk/benefit relationship," he stated. "And what we need to do as clinicians is work with our patients to understand what are their risks and benefits and then make a joint decision for what treatment seems to be the most effective. And we can mitigate these risks by what medication we select, what data is there, the dose we select, as well as the monitoring."

Dr. Timothy Wilens, director of substance abuse services in Massachusetts General Hospital's pediatric psychopharmacology clinic, discussed treating adult patients who have ADHD plus substance use disorder, conditions that have "a lot of overlap." Actually, Dr. Wilens and colleagues conducted a review of older studies, revealing that approximately 20% of adults with substance use disorders have ADHD. 

He cited 4 double-blind studies in which stimulants were used to treat patients with concurrent substance use disorders and ADHD. One trial evaluated pemoline in adolescents who abused substances, 2 assessed methylphenidate immediate-release or sustained-release in adults who abused cocaine, and 1 trial was conducted in adults on methadone who received methylphenidate sustained-release or bupropion sustained-release. In all, the treatments were safe and did not worsen the substance abuse, but neither did they significantly improve the substance abuse. Also, they only showed meager effects at reducing ADHD symptoms.

More recently, Dr. Wilens and other researchers evaluated atomoxetine in 147 adults who used alcohol, but who briefly abstained from it prior to treatment. They received atomoxetine (25 mg/day to 100 mg/d) or placebo for approximately 12 weeks; after that time, the atomoxetine arm showed significant improvements relative to the placebo group on ADHD Rating Scale outcomes. Those who received active therapy also demonstrated an approximately 24% greater reduction in the rate of heavy drinking relative to the placebo arm during the 12 weeks.

He also noted that results from a recent study that compared the Drug Rating Questionnaire Subject Liking Scores among patients who took intravenous or oral placebo, immediate-release d-amphetamine, or lisdexamfetamine. With 50 mg of IV lisdexamfetamine and 100 mg of oral lisdexamfetamine, likability was significantly less than with 20 mg of IV d-amphetamine and 40 mg of oral d-amphetamine, respectively.

Dr. Wilens referred clinicians to a 2005 consensus recommendation monograph from the University of Michigan about the need to treat patients with both ADHD and substance use disorders, and how to do so.

For example, he said that data suggest that it is best for patients to abstain from their substance use before initiating drug therapy.

"Even if it's brief abstinence, that appears to be better than no abstinence. Treating through active substance abuse is giving us the same signal of a lack of robustness for ADD treatment or substance abuse outcome," he explained.

Dr. Wilens concluded that in high-risk adults and adolescents, extended-release stimulants and nonstimulants are preferred over immediate-release formulations. Continued maintenance and monitoring are also important, he added.

This information concerns uses that have not been approved by the FDA.

By Shayna Muckerheide

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