US Pharm. 2018;43(4):8-12.
Attention-deficit/hyperactivity disorder (ADHD) is a brain condition than makes it difficult for children to control their behavior. It is one of the most common chronic conditions of childhood and is characterized by a continuing behavioral pattern of inattention, hyperactivity, and/or impulsivity that interferes with functioning or development.1
ADHD affects 4% to 12% of school-aged children. About three times more boys than girls are diagnosed with ADHD. These children often have difficulty getting along with other children at school, at home, and in other settings. Children who have trouble with attention often have trouble learning as well. Impulsivity may endanger them physically. More serious forms of ADHD in children can lead to serious, lifelong problems such as failing in school or in relationships and being unable to keep a job.1
Although there is no cure for ADHD, treatments are available that may help reduce symptoms and improve functioning. These include medication, psychotherapy, education or training, or a combination of these treatments. Although stimulants can be very effective and are the first choice for ADHD, they are not suitable for everyone. The focus of this article is on other effective options for ADHD such as nonstimulant drugs and psychotherapy.
A pediatrician can offer a long-term, effective treatment plan to help these young patients to have a happy and healthy life; parents also have an important role in treatment.2 Pharmacists are essential to the treatment team as they counsel children and families about the use of medication and what to expect from drug treatment.
Signs and Symptoms
Common signs and symptoms of ADHD include:
Inattention: A person with ADHD may overlook or miss details, lack persistence, have problems sustaining attention in tasks or in play, be disorganized and easily distracted by unrelated thoughts or stimuli, and seem not to listen when spoken to directly. In females, inattention is more likely to be a problem.1,2
Hyperactivity: The child seems to move about constantly, including in situations in which it is not appropriate, or excessively fidgets, taps, or talks. He or she may be unable to play or engage in hobbies quietly.1,2
Impulsivity: A person with ADHD may take action unexpectedly in the moment without first thinking about it; these actions may have high potential for harm. An impulsive person may be socially intrusive and excessively interrupt others, or make important decisions without considering the long-term consequences.1,2
Learning disabilities, anxiety disorders, conduct disorder, depression, and substance abuse are also common in people with ADHD.1 Researchers are not yet sure what causes ADHD, but it is believed that contributing factors may include genes, cigarette smoking, alcohol and drug use during pregnancy, exposure to environmental toxins (e.g., lead) during pregnancy and at a young age, low birth weight, and brain injuries.1,3
Diagnosis
Most pediatricians use guidelines developed by the American Academy of Pediatrics to determine whether or not a child has ADHD.2 To make a diagnosis of ADHD, the symptoms of inattention and/or hyperactivity-impulsivity must be long-lasting, impair functioning, and cause the person to fall behind normal development for his or her age. For an adolescent or adult to receive a diagnosis of ADHD, the symptoms need to have been present prior to age 12 years.1,3
Children as young as age 3 to 6 years can display ADHD symptoms, and these can persist through adolescence and adulthood. Symptoms of ADHD may be mistaken for emotional or disciplinary problems; in children who are quiet and well-behaved, symptoms may be missed completely, leading to a delay in diagnosis.
ADHD symptoms can change with age. In elementary school, the symptom of inattention may become more prominent and may cause a child to struggle academically. In high school, hyperactivity may seem to lessen in an adolescent and be manifested more often as feelings of restlessness, but inattention and impulsivity may remain. Many adolescents with ADHD also struggle with relationships and antisocial behaviors.1,4
Most pediatricians will also check for one or more coexisting conditions that show the same types of symptoms as ADHD. Common coexisting conditions are oppositional defiant disorder or conduct disorder, mood disorders, anxiety and depression disorders, and learning disabilities.4
Treatment
ADHD medications have an impressive effect, reducing hyperactivity and impulsivity and improving the ability to focus, work, and learn. They also may improve physical coordination. Sometimes several different medications or dosages must be tried before finding what works for a particular child.5
Methylphenidate and amphetamine in both short- and long-acting forms have been very effective in ADHD as psychostimulants.5 However, in some these drugs may not work very well, and some cannot tolerate the side effects.
Long-Acting Nonstimulants
Currently there are three FDA-approved nonstimulant drugs available. These medications take longer to start working than stimulants, but can also improve focus, attention, and impulsivity in a person with ADHD. All medications should be individualized according to the therapeutic needs and response of the patients.1,5
Atomoxetine (Strattera): Atomoxetine is the first nonstimulant drug approved for ADHD and is now used in both children and adults. This drug appears to increase the amount of norepinephrine in the brain. This may help ADHD by increasing attention span and reducing impulsive behavior and hyperactivity. Although it is frequently used to treat ADHD, it is less effective than psychostimulants. In 2006, a warning was added that there may be increased suicidal thoughts with atomoxetine early in the treatment process, and therefore, unusual behaviors should be promptly reported to a healthcare provider. Atomoxetine dosing for ADHD is as follows5:
In children aged ≥6 years and adolescents, weighing >70 kg, the oral initial dose is 0.5 mg/kg/day, increasing after a minimum of 3 days to 1.2 mg/kg/day. It may be administered once daily in the morning or divided into two doses and administered in the morning and late afternoon/early evening. Maximum daily dose is 1.4 mg/kg/day or 100 mg/day, whichever is less.5,6
In children aged ≥6 years and adolescents weighing >70 kg, and adults: oral initial dose is 40 mg daily and may be increased after a minimum of 3 days to ~80 mg daily, administered once daily in the morning or divided into two doses. After an additional 2-4 weeks, the dose may be increased (if needed) to a maximum daily dose of 100 mg/day.5,6
Dosage adjustment with concurrent use of strong CYP2D6 inhibitors (e.g., paroxetine, fluoxetine, quinidine) or in patients known to be CYP2D6 poor metabolizers is as follows: oral initial dose is 40 mg daily for 4 weeks and may be increased to 80 mg daily only if clinically needed (do not exceed 80 mg daily).5
Guanfacine ER (Intuniv): Guanfacine ER, an alpha-2-adrenergic agonist, is a once-daily, extended-release product in a matrix tablet formulation for oral administration only. It has an effect on certain receptors in the brain. Studies show that it reduces distractibility and improves attention, working memory, and impulse control. As Tenex, this drug is an extended-release medicine that is used to reduce blood pressure; it has been approved by the FDA to reduce ADHD related-symptoms.5,6 Dosing for ADHD is as follows:
Extended-release product, for children and adolescents aged 6 to 17 years: initial dose is 1 mg once daily administered at the same time of day (in the morning or evening); may titrate dose by no more than increments of 1 mg/week based upon response and as tolerated to the recommended target dose range of 1 mg to 7 mg/day. Do not substitute immediate-release guanfacine tablets on mg-per-mg basis, because of differing pharmacokinetic profiles.5,6
Clonidine ER (Kapvay): Clonidine ER is an alpha-2-adrenergic agonist available as 0.1-mg and 0.2-mg extended-release tablets; it may be used alone or with other psychostimulants. It is approved for ADHD in children aged 6 to 17 years. This drug is thought to work by inhibiting the release of norepinephrine in certain parts of the brain. It improves frustration tolerance and thereby reduces angry outbursts and/or violent behavior. Clonidine ER is also used for tics. Tics are spontaneous, purposeless, often repetitive movements or vocalizations—such as eye blinking, throat clearing, and verbal or nonverbal sounds—that may occur with ADHD.7 The dosing for children ≥6 years and adolescents is as follows:
Extended-release product (Kapvay): Initial dose is 0.1 mg at bedtime; increase in 0.1-mg/day increments every 7 days until the desired response is achieved; doses should be administered twice daily in the morning and at bedtime. Maximum daily dose: 0.4 mg/day. When discontinuing therapy, the daily dose must be tapered by ≤0.1 mg every 3 to 7 days.5,6
Children and adolescents may be switched to the transdermal delivery system after oral therapy is titrated to an optimal and stable dose; a transdermal dose approximately equivalent to the total oral daily dose may be used.
Nonstimulants have some advantages over many stimulants used for ADHD. They do not cause agitation or sleeplessness, do not pose the same risk of abuse or addiction, and have a longer-lasting and smoother effect than many stimulants. They may cause some side effects in the GI system, and may cause fatigue and dizziness.5,6
Antidepressants
Although not approved by the FDA specifically for the treatment of ADHD, antidepressants (tricyclics, bupropion, venlafaxine, and monoamine oxidase inhibitors can be prescribed if a patient has bothersome side effects from stimulants and nonstimulants. Antidepressants can be helpful in combination with stimulants and nonstimulants if a patient also has another condition, such as an anxiety disorder, depression, or another mood disorder.6
Psychotherapy
The addition of psychotherapy to other treatments for ADHD may improve patients’ and families’ understanding of the disorder, and help them cope with day-to-day problems.1,8
Behavioral therapy is a type of psychotherapy that teaches a person how to change his or her behavior. Techniques used may consist of practical assistance, such as help in organizing tasks or completing schoolwork, or working through emotionally difficult events. Learning how to monitor one’s own behavior or reward or praise oneself for acting in a desired way, such as controlling anger or thinking before acting, are additional skills taught in behavioral therapy for ADHD.1,8
Behavioral therapists may also teach children social skills, such as how to wait their turn, share toys, ask for help, or respond to teasing. Social-skills training may also include learning to read facial expressions and the tone of voice in others, and how to respond appropriately. Parents, teachers, and family members can also give positive or negative feedback for certain behaviors and help establish clear rules, chore lists, and other structured routines to help a person control his or her behavior.1,8
Cognitive-behavioral therapy may also teach mindfulness techniques or meditation, help the child learn to be aware and accepting of thoughts and feelings, and improve focus and concentration. The therapist also encourages the person with ADHD to adjust to the life changes that come with treatment, such as thinking before acting, or resisting the urge to take unnecessary risks.1
Education and Training
To reach their potential and succeed, children with ADHD require guidance and understanding from their parents, families, and teachers. Frustration, blame, and anger may have built up within a family before a child is diagnosed. To overcome these negative feelings, parents and children may need special help. Mental-health professionals can help the child and the parents develop new skills, attitudes, and ways of relating to each other.1,8
Behavioral parent-management training may teach parents the skills they need to encourage and reward positive behaviors in their children. This training helps parents learn how to use a system of rewards and consequences to change a child’s behavior.1,8
Learning stress-management techniques can help parents of children with ADHD to deal with frustration so that they can respond calmly to their child’s behavior. Support groups can help parents and families connect with others who are experiencing similar problems and concerns.1,8
Conclusion
ADHD is a highly prevalent condition among children. It is characterized by inattention, hyperactivity, and impulsivity. Successful treatment of ADHD depends on matching the child’s needs and lifestyle with specific regimens. Stimulant medications are typically the first-line treatment for ADHD; however, nonstimulant medications including atomoxetine, clonidine, guanfacine, and some antidepressants offer an alternative to first-line therapy. Pharmacists are essential in identifying potential drug-drug interactions and counseling caregivers and children about ADHD medications, including the potential adverse effects, precautions for use, and other considerations with nonstimulant therapies.
REFERENCES
1. National Institute of Mental Health. Health and education. Mental health information. Attention deficit hyperactivity disorder. Updated March 2016. www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml. Accessed February 12, 2018.
2. American Academy of Pediatrics. Diagnosing ADHD in children: guidelines and information for parents. www.healthychildren.org/English/health-issues/conditions/adhd/Pages/Diagnosing-ADHD-in-Children-Guidelines-Information-for-Parents.aspx. Accessed March 12, 1018.
3. Froehlich TE, Lanphear BP, Epstein JN, et al. Prevalence, recognition, and treatment of attention-deficit/hyperactivity disorder in a national sample of US children. Arch Pediatr Adolesc Med. 2007;161(9):857-864.
4. CHADD. The National Resource on ADHD. Coexisting conditions. www.chadd.org/Understanding-ADHD/About-ADHD/Coexisting-Conditions.aspx. Accessed March 13, 2018.
5. Attention deficit/hyperactivity disorder: nonstimulant therapy (Strattera) and other ADHD Drugs. www.medicinenet.com/script/main/art.asp?articlekey=41885. Accessed February 18, 2018.
6. Lexicomp Online. Clinical drug information. Hudson, OH: Lexi-comp, Inc. Accessed January 28, 2018.
7. Sprecher D, Kurlan R. The management of tics. Mov Disord. 2009;24(1)15-24.
8. American Academy of Pediatrics. Behavior therapy for children with ADHD. HealthyChildren.org. Updated January 9, 2017. www.healthychildren.org/English/health-issues/conditions/adhd/Pages/Behavior-Therapy-Parent-Training.aspx. Accessed March 12, 2018.
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