The Importance of Using Multiple Approaches When Treating Pediatric ADHD

In this video, Andrew Cutler, MD, debunks the myth that there is only one path to success when treating attention-deficit/hyperactivity disorder (ADHD) in children. Multiple approaches are often needed, he says, because of different clinical presentations and impairments, comorbidities, and patients' varying individual needs.

Dr. Cutler is clinical associate professor of psychiatry at SUNY Upstate Medical University, Syracuse, New York.

This is Part 1 of a 4-part video series marking ADHD Awareness Month, which is held in October.

Read the transcript:

Hello. I'm Dr. Andrew Cutler, chief medical officer of the Neuroscience Education Institute and clinical associate professor of psychiatry at SUNY Upstate Medical University.

There are many myths regarding ADHD. One of them is that there is only one management path to success with ADHD treatment. When the fact is that multiple approaches to treat ADHD are often needed. Now, why do I say that? Well, it has to do with many things regarding ADHD.

First of all, the symptoms themself can be very heterogeneous, and the clinical presentation can vary greatly from one child or adolescent to the next. If we look at the diagnostic criteria from DSM-5 there are 18 potential symptoms—9 inattentive and 9 hyperactive/impulsive—and you only need 6 out of the 9 of either or both of those 2 categories to qualify for the diagnosis. You can imagine that there are many different possible combinations of these symptoms that would qualify for the diagnosis of ADHD.

There are three major diagnostic categories of ADHD. Those are the combined presentation, the predominantly inattentive presentation, and the predominantly hyperactive/impulsive presentation. Those are 3 different clinical presentations.

Now, along with that, there are also different levels of impairment and different kinds of impairments that can be seen with children with ADHD. They may have more academic impairment. They may more social impairment. They may have more impairment at home or with peers.

They also may have different associated features. Some of the associated features of ADHD include insomnia or difficulty sleeping, problems with sensory processing, problems with emotional regulation, executive function problems.

There are also many psychiatric comorbidities that can be seen. The most common one in the child and adolescent age group is called ODD, oppositional defiant disorder. That really gets into the emotional and behavioral dysregulation that can be seen.

We can also see tic disorders, anxiety becomes quite common, depression starts to become common from childhood, especially into adolescence. Also, we can see problems with communication, such as dyslexia, reading, or arithmetic problems.

Again, the overall clinical presentation can vary quite greatly. Now, the other area that is very variable with ADHD that may result in the need to individualize the treatment is the neurobiology. We know, for instance, that the major neurochemical abnormality has to do with some abnormality in the signaling of the neurotransmitters norepinephrine and dopamine.

Now, there may be other chemicals involved as well, including serotonin, glutamate, GABA, acetylcholine, and histamine. We know that there are many different paths, parts of the signaling process, that with the neurotransmitter signaling cascade.

These neurotransmitters need to be synthesized, packaged, released, and there are receptors they bind to. Then, once they bind to the receptors, there are various second-messenger systems and various things that get activated.

This is a very complicated process, and anywhere along the process can be disrupted. Now, we know the circuitry also is complicated and can be variable from one patient to the next. The majority of the pathology seems to be problems with the prefrontal cortex.

Now, the prefrontal cortex regulates 3 different circuits, including circuits that have to do with attention, circuits that have to do with hyperactivity and impulsivity, and circuits that have to do with emotional regulation and emotional responsiveness.

Now, we know that some children can have more problems in 1, 2, or all 3 of these different pathways, again, resulting in different clinical presentations. Overall, the clinical presentation is quite heterogeneous and variable. The underlying neurobiology can also be variable from one patient to the next.

This leads us to treatment and the importance of individualizing treatment. Now, if we look at the medications that have been approved to treat ADHD, there is the category of stimulants. The stimulants divide into two types of chemicals, methylphenidates and amphetamines.

Right there, it's very important to recognize that you need to individualize, because there is a 30 percent preferential response rate. Meaning that about 30 percent of the time, a child will respond better to or tolerate better one or the other, either the methylphenidate or the amphetamine. It's very important to realize that, if you try one of them, and it doesn't seem to work, or it’s not tolerated, the right path is not to try a different methylphenidate, for instance, but to switch over to an amphetamine.

Now, the other way that these stimulants vary is in the formulations and especially the pharmacokinetics, the release patterns. Both the onset of efficacy and then the duration of action. We have some that are immediate-release, some that are extended-release, and then some that really are much longer, that can last not only 10 or 12 hours of the day, but can go as long as 16 hours out of the day. It's really important to individualize, based on the situation and the child's needs, what duration of action and how fast the onset might be.

Now, there are three FDA-approved nonstimulants, and these include atomoxetine, extended-release guanfacine, and extended-release clonidine.

Now, these medications vary as well. The atomoxetine is a norepinephrine reuptake inhibitor, not as universally or consistently effective as stimulants, but certainly an important option for some patients, particularly those who might have some concomitant anxiety.

The alpha-2 agonists, which are the extended-release guanfacine and clonidine, can be used as monotherapy. They are limited, however, by sedation and are really often used in combination with a stimulant. They can be helpful for treating some of the associated comorbidities as far as emotional-behavioral dysregulation and oppositional defiant disorder. And they may have some beneficial effects in children who have tic disorders as well.

Now, not only is it important to individualize the medication treatment and the choice of medications, sometimes, we have to use combinations of medicines—as I mentioned, a stimulant and an alpha-2 agonist—but, sometimes, we have to add a medication to treat some of the comorbidities, such as an SSRI to treat depression or anxiety.

Not only is it important to really think carefully about and individualize the medication treatment, it's also important to individualize the nonpharmacologic treatments that we can offer. We have many different options.

Most commonly, what's recommended, of course, is behavioral therapy, which can include parent training and various other forms of behavioral therapy interventions. Psychoeducation, of course, is critical, and should probably be used with all families of children with ADHD.

There also are techniques that help the parent with organizational skills, because some children have more or less problems with executive function and things like organizing and planning ahead.

I hope that I have given you a little taste of why I believe that multiple approaches are often needed to treat ADHD to be successful.

It's very important to be very careful in your diagnosis and the clinical presentation, the type of ADHD, the presentation that you're dealing with, as well as any associated features or any comorbidities, and it's important to think about the individual child's activities throughout the day.

In other words, are they involved in after-school sports, for instance, where it might be very important to have a longer duration of action? Do they have a lot of activities on the weekends? Do they have a lot of trouble with socialization, and might they need some help with those kinds of skills that can be developed?

I want to thank you very much for your attention.